Rn case manager remote jobs in Miami, FloridaCreate job alerts

JOB DESCRIPTION Looking for a RN that has a current active unrestricted license This a remote role and can sit anywhere within the United States. Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule) Looking for a RN with experience with appeals, claims review, and medical coding. Job Summary Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Job Duties • Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing., • Identifies and reports quality of care issues., • Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience, • Documents clinical review summaries, bill audit findings and audit details in the database, • Provides supporting documentation for denial and modification of payment decisions, • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care., • Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions., • Supplies criteria supporting all recommendations for denial or modification of payment decisions., • Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals., • Provides training and support to clinical peers., • Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol. JOB QUALIFICATIONS Graduate from an Accredited School of Nursing REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: • Minimum 3 years clinical nursing experience., • Minimum one year Utilization Review and/or Medical Claims Review., • Minimum two years of experience in Claims Auditing, Medical Necessity Review and Coding experience Active, unrestricted State Registered Nursing (RN) license in good standing. PREFERRED EDUCATION: Bachelors’s Degree in Nursing or Health Related Field PREFERRED EXPERIENCE: Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics. Advanced Practice Nursing. Billing and coding experience. PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: Certified Clinical Coder, Certified Medical Audit Specialists, Certified Case Manager , Certified Professional Healthcare Management, Certified Professional in Healthcare Quality or other healthcare certification. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. We are seeking a candidate with a WA state RN licensure to support the Washington State Plan. Candidates with knowledge of the criminal justice system, or carceral facility knowledge/work experience are highly preferred. Candidates must have previous case management, discharge planning or care coordination experience Bilingual candidates that speak fluent Spanish are encouraged to apply to support our diverse communities. Further details to be discussed during our interview process. Remote position Work schedule: Monday- Friday: 7:30am- 4:30pm PST. RN WA licensure required KNOWLEDGE/SKILLS/ABILITIES • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment., • Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals., • Conducts face-to-face or home visits as required., • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly., • Maintains ongoing member case load for regular outreach and management., • Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members., • Facilitates interdisciplinary care team meetings and informal ICT collaboration., • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts., • Assesses for barriers to care, provides care coordination and assistance to member to address concerns., • 25- 40% local travel required., • RNs provide consultation, recommendations and education as appropriate to non-RN case managers., • RNs are assigned cases with members who have complex medical conditions and medication regimens Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association Active, unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job DescriptionSalary: Open **IMMEDIATE OPENING Job Highlights The Case Manager will be responsible for coordinating and overseeing the care of patients, collaborating with healthcare providers, and ensuring the delivery of high-quality, personalized care. The role involves assessing patient needs, developing care plans, monitoring progress, and advocating for patients. Coordinates patient care in compliance to regulations and quality improvement of the Home Health Agency; order and authorization review, assignment of field staff, utilization management, the nursing process- development planning, implementation, and updates of the plan of care under the scope of the state RN licensure. The Case Manager prepares transfer and discharge summaries, maintain patient census, and assures interdisciplinary case coordination. Qualifications • MUST HAVE HOME HEALTH EXPERIENCE, • Minimum of an Associates degree, BSN preferred., • Minimum of three (3) year of related experience in home healthcare, • Active Registered Nurse (RN) license in the State of Florida, • Strong organizational and time management skills, • Excellent communication and interpersonal skills, • Ability to work effectively in a team environment, • Experience in case management or healthcare coordination, • Knowledge of healthcare regulations and patient advocacy, • Empathy and compassion for patients and their families', • Knowledge of EMR and computer programs a plus Responsibilities • Develop individualized care plans based on assessment findings, • Collaborate with other healthcare professionals to coordinate patient care, • Monitor and evaluate the effectiveness of nursing programs and make recommendations for improvement, • Ensure compliance with all regulatory requirements, including HIPAA and medical record documentation, • Collaborate with other healthcare professionals to develop and implement patient care plans, • Develop and implement nursing policies and procedures to ensure high-quality patient care, • Document all patient interactions, interventions, and outcomes accurately and timely Benefits: • Pay: Open, • Location: In-Person/Remote, • Job Type: Full Time, • Hours of Operation: Monday thru Friday, • On Call, • Weekends PRN Special Requirements * Must have a car with required insurance coverage and a state driver's license or reliable transportation Functional Abilities • Able to communicate verbally and in writing to the extent required by the position, • Able to physically perform the duties required by the position

RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens. Active, unrestricted Certified Case Manager (CCM).

RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed. Preferred License, Certification, Association Active, u

RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens. Active, unrestricted Certified Case Manager (CCM).