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Just FYI if anyone is interested there are plenty of openings. For more information please PM me the following:
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Description
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Location: Virginia Beach, VA -*This*is not a work from home position
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***11/9/2015 and 11/30/15 Training Classes***
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This position is*responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
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This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. Primary duties may include, but are not limited to:
Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistentwith*the member's eligibility, benefits and contract.Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.Applies clinical knowledge to work with facilities and providers for care-coordination.May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
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Qualifications
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Requirements:*
Requires*an active*LPN, LVN, or RN license; 2 years of clinical or utilization review experience1 year of managed care experience and knowledge of the medical* management process; or any combination of education and experience* which would provide an equivalent backgroundCurrent unrestricted license or certification in*Virginia*is requiredMust be able to work any hours of operations from 7 AM-7PMMust have experience with electronic documentation
Preferred:
Medicaid or Medicare experience
**This position will sit in our VB location and is not a work from home job.**
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