UM reputed company, RN (Weekend Shift)

reputed company What you can expect! reputed company reputed company in serving others with reputed company! We welcome you to join us in “healing and inspiring the reputed company spirit” and to pivot from a “job” opportunity to an authentic experience! Under the general direction of the Utilization Management Manager, the Utilization Management reputed company is responsible for prospective and reputed company/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of reputed company in Member correspondence. This position is responsible to ensure meeting Member’s needs using nationally recognized UM reputed company. Commitment to reputed company: The reputed company Team is committed to incorporate reputed company’s reputed company Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks reputed company is not only committed to healing and inspiring the reputed company spirit of our Members, but we also aim to match reputed company members with the reputed company energy by providing reputed company benefits and more.

• Competitive salary
• Telecommute schedule
• State of the art fitness center on-site
• Medical Insurance with Dental and reputed company
• Life, short-term, and long-term disability reputed company
• Career advancement opportunities and reputed company development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) reputed company with a contribution match
• reputed company life insurance for employees
• Pet care insurance

Key Responsibilities

• Responsible for reviewing prospective, reputed company, and retrospective reviews for medical necessity and appropriateness of service and care including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and any high dollar cases.
• Responsible for the prospective and retrospective review of referral denials, denial letters, and logs to determine appropriateness of denial, possible alternative treatment, and evaluation for case management or reputed company of care issues in collaboration and direction of UM Medical Director.
• Draft denial language to ensure consistent application of standardized, nationally recognized UM reputed company and appropriate use of denial language.
• Work closely with Medical Directors to ensure consistent use of guidelines/reputed company.
• Create and maintain a standardized reputed company of denial language split by reputed company for reputed company use.
• Responsible for assisting with the letter of agreement process reputed company referring Members to out-o-network providers.
• Review and report reputed company review findings with UM Management in order to support requirements of accuracy and productivity on a monthly reputed company.
• Screen medical information provided and authorization requests for medical necessity and appropriateness, comparing the information to reputed company reputed company and discussing with Medical Directors.
• Support reputed company of UM Team with benefit interpretation and understanding of UM policies and procedures.
• Assist Medical Directors with benefit interpretation, obtaining additional medical necessity information and researching issues.
• Assist Medical Directors with revisions to reputed company UM Subcommittee Guidelines to ensure appropriate interpretation of reputed company.
• Attend staff meetings and education trainings necessary to maintain reputed company nursing and UM knowledge.
• Participate reputed company in LEAN activates to support the goals of the Department.
• Assist with the utilization management reputed company of the Medical Management audit, as reputed company as reputed company referral and denial audits.

Qualifications

Education & Requirements

• Two (2) or more years of utilization management experience in a health care delivery setting specifically in prior authorization or two (2) or more years of experience in an acute care facility
• Experience in an HMO or experience in a Managed Care setting preferred
• High school diploma or GED required
• Bachelor's degree in Nursing from an accredited institution preferred
• Possession of an reputed company, unrestricted, and unencumbered Registered reputed company (RN) license issued by the California BRN required

Key Qualifications

• Must have a valid California reputed company’s license
• Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements specifically as they relate to UM/Health Plan correspondence.
• Exhibits a high attention to detail in documenting UM referral reviews
• Ability to work at a high level of speed while maintaining accuracy
• Ability to work reputed company with both physician and nursing staff

Start your reputed company towards a thriving reputed company with reputed company and apply TODAY! Work Model Location Telecommute (reputed company reputed company positions approved for telecommute work locations may periodically be required to report to reputed company’s main reputed company for mandatory in-person meetings or for other business needs as determined by reputed company leadership) Pay reputed company USD $91,249.60 - USD $120,910.40 /Yr. Apply tot his job Apply To this Job