Registered NurseHEALTH NOW ADMINISTRATIVE SERVICES
Comprehensive Care Management
We're growing our team!
We have an immediate opening for an experienced Registered Nurse:
- 3 years Clinical experience
- 1+ years in a hospital setting
- Associates degree (nursing) req'd
- Bilingual (english/spanish) preferred
Apply visit our website: www.hnas.com
Select Contact Us then Careers Posting 1427BR
Drug-free workplace. EOE/AA M/F/D/V
Provides comprehensive care management services for external clients and for all lines of business in conjunction with strategic business partnerships, all applicable regulatory guidelines and any applicable specific state requirements. Comprehensive care management functions include Utilization Management, Case Management, Disease Management and Cost Containment, providing the continuum of health services necessary to improve health, prevent and control disease and have a measurable impact on health related costs.
Performs a complete review for medical necessity, pre service, post service, or concurrent, using criteria, medical policy and submitted medical information, with Medical Director review as indicated. The RN will complete the appropriate notification processes. Demonstrates the ability to triage incoming calls for urgency and comply with regulatory processes. Depending on the type of request, the RN must possess the knowledge of applying the appropriate timeframes to the request and meet those timeframes for requesting medical records or sending out the decision of the request. Along with the timeframes, when requesting records, the RN must demonstrate the ability to be compliant with HIPAA (Health Insurance Portability and Accountability Act) on the information being requested. Provides cost effective claim negotiation services with out-of-network (OON) providers for precertified medically necessary health services, in coordination with the client, and as per plan provisions. Facilitates and provides adverse determination case appeal reviews as requested, and as appropriate, based on a member's appeal rights, plan provisions and applicable regulatory guidelines. Acts as an advocate and liaison to meet a member's individual health care needs, the RN will assess, plan, implement, coordinate, monitor and evaluate options and services. This is accomplished by using communication and available resources to educate the member and to promote quality, cost-effective. Exhibits and applies clinical understanding of the medical diagnosis (es), case and disease management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals. Exhibits and applies clinical understanding of the medical diagnosis (es), case and disease management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals. Performs other related duties as requires.
Excellent time management skills with ability to multi-task Excellent organizational skills and attention to detail Excellent verbal and written communication skills Strategic thinking/planning/problem-solving skills Ability to work effectively with minor supervision, independently and with the team Must be able to work in a fast-paced environment with daily work processing deadlines High degree of business maturity and demonstrated confidentiality, HIPAA compliant High energy level and ability to project enthusiasm Persuasive communication style Polished, professional image and reputation Demonstrated personal accountability Excellent computer skills with ability to work in multiple software programs including MS Word, MS Excel, MS PowerPoint, MS Access, Visio Knowledge/experience in all aspects of care management and the health insurance industry Knowledge/experience in medical management of self funded (ASO) health plans desired Experience with claim review, ICD-9, CPT coding preferred Stop-loss claim experience desired.
HealthNow Administrative Services (HNAS) is a wholly-owned subsidiary of HealthNow New York, Inc., a health insurance carrier headquartered in Buffalo, New York. With offices in Pennsylvania, New Jersey, Arizona and California, HNAS is a nationally recognized group benefit plan marketer and administrator. HNAS specializes in custom-designed employee benefit programs and Third Party Administration (TPA) and partner services, self-funded health insurance, and consumer driven health care plans as well as health management solutions. HNAS provides employee benefit solutions integrated with administrative and claims services. For more information, you can visit www.hnas.com.