Nurse RN 5 3 months Potential to extend/convert depending on the business needs Remote in California 8:00-3:30 PST
Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
Triages and prioritizes cases to meet required turn-around times.
Prepares and presents cases electronically to the Medical Director (MD) for approvals or denials and medical necessity determination.
Communicate determinations to providers in compliance with state, federal and accreditation requirements.
Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary.
Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
Required: Strong clinical skills Strong computer skills Works well independently
Preferred: Previous Post Service Experience Previous Prior Auth Experience Previous Case Management experience
Software Skills Required: Word, Internet search engine, limited excel required Disqualifiers/ Dislikes on Resumes: Limited clinical experience and/or multiple job hopping
Applicant Notices & Disclaimers
For information on benefits, equal opportunity employment, and location-specific applicant notices, click here
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 55.00/hr.
