Job Description

**Duration: 3+ Months Contract (Possible temp to hire)** **Job Description:** + Must be an RN in SC and have an active and unrestricted SC RN license. + Hours/Schedule - Monday-Friday, 8:30AM-5PM + Will be required to be onsite for at least 1 month and if progressing well, can be moved to work remote. + Prefer 2 yrs. UM and/or appeals experience. + Experience with prior insurance, utilization management, case management, surgical or behavioral health experience. This role conducts reviews of previously denied services to determine if the medical necessity and contract provisions have been applied correctly or if newly submitted information would change the determination. + Must have broad clinical background, flexibility **.** **Responsibilities:** + Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. + Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. + Documents decisions within mandated timeframes and in compliance with applicable regulations or standards. + Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. + Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. + Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. + Performs special projects including reviews of clinical information to identify quality of care issues. **Experience:** + 3 years clinical experience or 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health. **Skills:** + Working knowledge of word processing software. + Ability to work independently, prioritize effectively, and make sound decisions. + Good judgment skills. + Demonstrated customer service, organizational, and presentation skills. + Demonstrated proficiency in spelling, punctuation, and grammar skills. + Demonstrated oral and written communication skills. + Ability to persuade, negotiate, or influence others. + Analytical or critical thinking skills. + Ability to handle confidential or sensitive information with discretion. **Education:** + Associate Degree - Nursing. **About US Tech Solutions:** US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit ( . US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Tags

Contract work, Temporary work, Remote work, Monday to Friday,

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