Nurse RN 3

Title: Nurse RN 3

Duration: 6 Months Possible extension (Contract to Hire/ Temp to Perm)

Shift: 8am to 5pm PST Monday - Friday.

Location: Remote CA

PR: $45-52.85/hr

• Perform prospective concurrent and retrospective utilization reviews and first level determination approvals for members using CMS evidenced based guidelines policies and nationally recognized clinal criteria for the Medicare line of business.
• Ensure discharge planning at appropriate levels of care for the members needs and acuity.
• Durable medical equipment and post service needs to ensure quality and cost-appropriate DC planning.
• Prepare and present cases to Medical Director for oversight/necessity determination and communicate determinations to providers and members to comply with state federal and accreditation requirements.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identify potential quality of care issues service or treatment delays and intervene as clinically appropriate.
• Refer to Case Management when there are acute inpatient needs affecting discharge.
• Attend staff meetings clinical rounds and weekly huddles.
• Maintain quality and productivity metrics for all casework.
• Maintaining HIPAA compliant workspace for telework environment.

• Associates degree in nursing required. Bachelors degree preferred.
• CA Nursing license required.
• Minimum of 5 years of experience in the inpatient hospital setting is required

• Verbal communication skills attention to detail and problem-solving skills.
• Self-driven able to work independently
• Strong clinical background and critical thinking skills
• Able to multitask while prioritizing cases to meet regulatory and business needs

• Windows excel and outlook.

• No Clinical experience. Many Short-term Jobs without explanation. Poor Computer Skills