Job added in hotlist
Applied job
Contract job
90-day-old-job
part-time-job
Recruiter job
Employer job
Expanded search
Apply online not available
Similar Jobs
View more jobs in Nashville, TN
View more jobs in Tennessee

Job Details

Licensed Utilization Review II Call Center Nurse- Nashville TN- 9/17 Start Date PS9752

Location
Nashville, TN

Apply for this job






7 hit(s)  

Profile

Job Description:
**MEMBERS ONLY**SIGN UP NOW***. is the nation's leading health benefits company serving the needs of approximately 40 million medical members nationwide.
Your Talent. Our Vision.
At Amerigroup, Inc.,
it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at
one of America's leading health benefits companies and a Fortune Top 50 Company.
 
 
Nurses for this position must be comfortable working any eight hour shift Monday-Friday between 7am-6pm. The start date for these positions is September 17th.
 
 
Licensed Utilization Review II (Call Center Nurse)-Medicare
 
 
The Licensed Utilization Review Nurse is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines that require the use of critical thinking/nursing judgment. Primary duties may include, but are not limited to: 
Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. 
Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. 
Applies clinical knowledge to work with facilities and providers for care coordination. 
May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. 
Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. 
Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. 
Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. 
Requires an LPN, LVN, or RN; 2 years of acute care or utilization review experience; or any combination of education and experience, which would provide an equivalent background. 
Current active unrestricted license in VA, or multi-state license in the state of residence if state is participatory in the nursing licensure compact.
Knowledge of the medical management process preferred.
Microsoft Office experience highly preferred.
Previous call center experience preferred.
Ability to obtain license in other states is preferred.
**MEMBERS ONLY**SIGN UP NOW***. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. Equal Opportunity Employer. M/F/Disability/Veteran.
Apply Now
Your Talent. Our Vision. At Amerigroup, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.
Nurses for this position must be comfortable working any eight hour shift Monday-Friday between 7am-6pm. The start date for these positions is September 17th.
Licensed Utilization Review II (Call Center Nurse)-Medicare
The Licensed Utilization Review Nurse is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines that require the use of critical thinking/nursing judgment. Primary duties may include, but are not limited to: 
Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. 
Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. 
Applies clinical knowledge to work with facilities and providers for care coordination. 
May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. 
Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. 
Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. 
Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. 
Requires an LPN, LVN, or RN; 2 years of acute care or utilization review experience; or any combination of education and experience, which would provide an equivalent background. 
Current active unrestricted license in VA, or multi-state license in the state of residence if state is participatory in the nursing licensure compact.
Knowledge of the medical management process preferred.
Microsoft Office experience highly preferred.
Previous call center experience preferred.
Ability to obtain license in other states is preferred.
**MEMBERS ONLY**SIGN UP NOW***. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. Equal Opportunity Employer. M/F/Disability/Veteran.
More Info
Our Mission
**** Disabled Person, Inc. | Terms and Privacy Policy
Donate
Want to be a sponsor?
Contact Us

Company info

Sign Up Now - CallCenterCrossing.com

I was very pleased with the CallCenterCrossing. I found a great position within a short amount of time … I definitely recommend this to anyone looking for a better opportunity.
Jose M - Santa Cruz, CA
  • All we do is research jobs.
  • Our team of researchers, programmers, and analysts find you jobs from over 1,000 career pages and other sources
  • Our members get more interviews and jobs than people who use "public job boards"
Shoot for the moon. Even if you miss it, you will land among the stars.
CallCenterCrossing - #1 Job Aggregation and Private Job-Opening Research Service — The Most Quality Jobs Anywhere
CallCenterCrossing is the first job consolidation service in the employment industry to seek to include every job that exists in the world.
Copyright © 2018 CallCenterCrossing - All rights reserved. 168