Remote UM Nurse - Pre-Service (Must have North Carolina LVN / RN License)

Required: Minimum (3) years' nursing experience in clinical setting. Minimum (1) year experience UM experience with pre-service. Minimum (1) year experience with managed care (Medicaid and / or Medicare). Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.) Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred Minimum (1) Experience with the application of clinical criteria, specifically MCG (Milliman Care Guidelines) Education Required: High School Diploma or GED. Preferred: Associates or Bachelor's degree in Nursing Licensure Required: Possess current, active and unrestricted LVN and / or RN license in North Carolina (Compact) Immediately upon hire, must obtain LVN and / or RN licensure in California (non-compact), Nevada, (Non-compact), Arizona (Compact), and Texas (Compact) which will be reimbursed by company. Preferred: CPHQ or ABQAURP, or Six Sigma certification Medical Terminology Certificate. Training Required: None Preferred: Medical Terminology. Six Sigma Specialized Skills Required: Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system (Access Express / Portal / N-coder). Knowledgeable with CMS (Chapter 13) guidelines and regulations. Computer Skills: Word, Excel, Microsoft Outlook Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors. Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly. Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: Bilingual (English / Spanish) Transplant knowledge a plus Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Need help crafting an effective cover letter and resume for this role?

Get access to our expert resources: our proven framework offers successful strategies, helps you find the best-fit positions, craft standout cover letters, optimize your resume, and much more.

Get Started