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Overview
HealthEdge ® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge .com.
Overview:
Telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer. In addition to performing prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum.
This candidate will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
RESPONSIBILITIES/TASKS:
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc.
Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
Communicates with providers and other parties to facilitate care/treatment.
Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Other duties may be assigned based on designated department assignment.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS:
EDUCATION:
Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE:
2+ years of acute clinical experience as RN required.
One (1) year health insurance plan experience or managed care environment preferred.
1+ years Behavioral Health clinical experience
1+ years Managed Care of Utilization Management experience.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
Working knowledge of current industry Microsoft Office Suite PC applications.
Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
Knowledge of current standard medical procedures/practices and their application as well as current trends and developments 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, local, state and federal regulations.
Other related skills and/or abilities may be required to perform this job based upon designated department assignment.
Geographic Responsibility: Remote, US Type of Employment: Full-time, permanent FLSA Classification (USA Only): Exempt Work Environment: 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:
The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
Work across multiple time zones in a hybrid or remote work environment.
Long periods of time sitting and/or standing in front of a computer using video technology.
May require travel dependent on company needs.
The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.
HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.
* The annual US base salary range for this position is $65,000 to $85,000 . This salary range may cover multiple career levels at HealthEdge . Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.