telephonic case manager.

Market leading healthcare organization looking for a remote RN or LPN Case Manager! Must have behavioral health and experience with eating disorders.

Duties: Clinical Evaluation and Review

- Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)

- Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.

- Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards

- Provide notifications to member and/or provider, according to regulatory requirements.

- Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.

- May coordinate peer-to-peer review upon provider request when members' health conditions do not meet guidelines

Collaboration and Documentation

- Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work

- Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information

- Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

Qualifications: Must have and maintain a valid and applicable RN or LPN clinical license (NC or compact multi-state licensure) to perform described job duties.

Shift: M-F 8 hour day shift

Potential for long term based on performance!


Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.