• Job Description

  Req#: JP-004234694

  100% remote, MUST have ACTIVE CA RN License, MUST reside in one of the following states:

  GA, FL, NV, WY, IL, VA , TX, NC, OR, ND, IN, PA, NH, AL, LA, CO, MN, OH, VT

  Description:

  This position facilitates utilization management (UM) processes to support that the right care is provided at the right place and at the right time. To accomplish these goals, he/she applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the Facility Acute Care Manager (CM). This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team, patient, family and others as necessary.

  Utilization Review:

  • The process of measuring and assessing the use of professional care, services, procedures, and facilities, including the medical necessity and appropriateness of setting, using evidence based criteria.

  • Perform daily preadmission, admission, and/or concurrent UR review using defined and standard policies and procedures, chart review, and discussions with providers of care; or other information to determine appropriate levels of care and/or readiness for care transition.

  • Consistently meets and maintains system standards for volume (productivity) and accuracy of utilization reviews, and participate in the communication of clinical information to payers/insurances.

  • Proficient in the use of evidence-based criteria used as screening tool to assist in determining if the proposed services are clinically indicated and provided in the appropriate level of care; or whether further evaluation is required.

  • Escalate unresolved utilization and systems problems, delays or barriers to leadership.

  • Monitor progression of the plan of care and facilitates discussions with the multidisciplinary teams.

  • Educate other health care team members on utilization and cost containment initiatives.

  • Employs effective use of knowledge, critical thinking and skills to advocate quality care, prevent patient complications during hospital stays and advocate for decrease hospital stay when appropriate.

  • Collaborate with facility case managers and facility case management leadership, to provide feedback and guidance in matters related to utilization reviews.

  • Participate in the assessment of the needs, risks, and benefits prior to determining the appropriate utilization of resources and coordinate with CMs and other healthcare officials to ensure effective provision of services, seeking resolution in a cost effective manner.

  • Completes initial InterQual or MCG review screening for all patients placed in a hospital bed and documents either inpatient or OBS status.

  • Performs InterQual or MCG continued stay reviews.

  • Reviews medical record to ensure patient continues to meet level of care (LOC) requirements and that chart documentation supports LOC determination and assignment.

  Additional Skills & Qualifications:

  - 2 years of experience within case management / utilization review is required

  - 1 year (minimum) of recent experience using InterQual/MCG is required

  - Education: BSN or related bachelors degree is required

  - CALIFORNIA RN LICENSE IS REQUIRED; compact licenses will not be accepted.

  - Must be in the following approved states: OR, NV, WY, CO, TX, ND, MN, WI, IL, IN, AL, VT, NH, PA, VA, NC, GA, FL, OH, LA.

  -Must be able to work flexible schedule

  Diversity, Equity & Inclusion

  At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

  • Hiring diverse talent
  • Maintaining an inclusive environment through persistent self-reflection
  • Building a culture of care, engagement, and recognition with clear outcomes
  • Ensuring growth opportunities for our people

  Actalent is an equal opportunity employer.

  About Actalent

  Actalent connects passion with purpose. We help visionary companies advance their engineering and science initiatives through access to specialized experts that drive scale, innovation, and speed to market. With a network of almost 30,000 engineering and sciences consultants and more than 4,500 clients across the U.S., Canada, Asia, and Europe, Actalent serves many of the Fortune 500. An operating company of Allegis Group, the global leader in talent solutions, Actalent launched as a new specialized engineering and sciences services and workforce solutions brand in 2021.

• About the company

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