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
  
 
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.