RN, Behavioral Health

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $65k - $85k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Provide telephonic coordination and delivery of clinical behavioral health services • Perform prospective, concurrent and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services • Assess medical necessity, appropriate length of stay, intensity of service and level of care • Review, research and authorize elective, direct, ancillary, urgent and emergency service requests • Identify and recommend alternative treatments, service levels and lengths of stay using approved clinical protocols • Analyze and prepare documentation for retrospective reviews and appeals in accordance with regulatory and accreditation standards • Establish, coordinate and communicate discharge planning needs • Research and resolve benefit, eligibility, non-authorized service, coordination-of-benefits and care coordination issues • Develop and deliver targeted education for providers • Communicate with providers and other parties to facilitate care and treatment • Identify referral opportunities and promote quality and effective healthcare service and benefit utilization • Consult with internal and external constituents on utilization and benefit management • Coordinate, document and communicate all aspects of the utilization/benefit management program

🎯 Requirements

• Current unrestricted Registered Nurse license required • 2+ years of acute clinical experience as RN required • 1+ years Behavioral Health clinical experience • 1+ years Managed Care or Utilization Management experience • One year health insurance plan experience or managed care environment preferred • Certification in Case Management may be preferred based upon designated department assignment • Certification or progress toward certification is highly preferred and encouraged • Excellent written and verbal communication skills • Excellent customer service and interpersonal skills • Working knowledge of Microsoft Office Suite PC applications • Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management • Knowledge of standard medical procedures/practices, current trends in medicine and nursing, alternative care settings and levels of service • Knowledge of policies and procedures, member benefits and community resources • Knowledge of applicable accreditation standards and local, state and federal regulations • Candidates may be required to complete a pre-employment criminal background check

🏖️ Benefits

• Full-time, permanent employment • Remote work environment • May require travel dependent on company needs • Reasonable accommodations for individuals with disabilities • Equal opportunity employer committed to workforce diversity