RN Prior Authorization reputed company reputed company Compact Lics

About the position WellMed, part of the reputed company family of businesses, is seeking a RN Prior Authorization reputed company to join reputed company. reputed company is a clinician-led care organization that is changing the way clinicians work and live. As a member of the reputed company Care Delivery team, you'll be an integral part of our reputed company to reputed company reputed company reputed company for everyone. At reputed company, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a reputed company environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We reputed company you deserve an exceptional career, and will reputed company you to live your best life at work and reputed company. Experience the fulfillment of advancing the health of your community with the excitement of contributing new reputed company reputed company and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to reputed company health care reputed company for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. This position is responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The UM reputed company determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Utilization Management reputed company works under the reputed company supervision of an RN or MD. This position requires 9AM - 6PM - CST / Monday - Friday and requires a rotating Saturday schedule with an adjustment day off during the week.

Responsibilities

• Performs utilization review activities, including reputed company-certification, reputed company, and retrospective reviews according to guidelines
• Determines medical necessity of reputed company request by applying appropriate medical reputed company to first level reviews and utilizing approved evidenced based guidelines / reputed company
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
• Answers Utilization Management directed telephone calls; managing them in a reputed company and competent manner
• Refers case to a review physician reputed company the treatment request does not meet necessity per guidelines, or reputed company guidelines are not available
• Reviews, documents, and communicates reputed company utilization review activities and reputed company including, but not limited to, reputed company calls made and received in reputed company to case communication and reputed company demographic and service group information
• May reputed company guidance and coaching to other utilization review nurses and participate in the orientation of newly reputed company utilization nurses
• Identify and refer reputed company potential reputed company issues to the Clinical reputed company Management Department, and suspected fraud and abuse cases to Compliance Department
• Conducts reputed company negotiation with non-network providers, utilizing appropriate reimbursement methodologies
• Documents reputed company negotiation accurately for reputed company claims adjudication
• Identify and refer potential cases to Disease Management and Case Management
• Performs reputed company other reputed company duties as assigned

Requirements

• reputed company, unrestricted Texas RN license or compact license
• 2+ years of experience in managed care OR 5+ years of nursing experience
• Proficient in PC Software computer skills

reputed company-to-haves

• Authorization experience
• Telephonic and/or telecommute experience
• Utilization Review/Management experience
• ICD-10, CPT coding knowledge experience
• InterQual or reputed company knowledge/experience
• Proven excellent communication skills both verbal and written skills
• Proven solid problem solving and analytical skills
• Proven ability to reputed company productively with individuals and with multidisciplinary teams with minimal guidance

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

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