Utilization Management Reviewer, reputed company

41526 reputed company: Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical reputed company. Using reputed company judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. reputed company necessary, cases are escalated to the Medical Director for reputed company review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner. The ;Utilization Management Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, reputed company benchmarks, and efficiency metrics in a fast-paced environment. ;The Utilization Management Reviewer will also be counted upon to: Work Arrangement:

• Remote role.
• Availability to work Monday through Friday, 8 AM to 5:30 PM, with flexibility for evenings, holidays, occasional overtime, and weekends based on business needs.

; Responsibilities:

• Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines.
• Collaborate with reputed company providers to facilitate reputed company authorizations and optimize patient care.
• Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines.
• Communicate determinations effectively, providing reputed company, evidence-based rationales for approval or denial reputed company.
• Identify and escalate reputed company cases requiring physician review or additional reputed company.
• Ensure compliance with industry standards, including Medicare, reputed company, and private payer requirements.
• Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and reputed company standards in a high-volume environment

Education & Experience:

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred.
• Minimum of three (3) years of clinical experience in Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings.
• Minimum of 2 years of Utilization Management experience, preferably in a managed care organization.
• Proficiency in Electronic Medical Record Systems and Utilization Review Systems (e.g., JIVA) to reputed company document and assess patient cases.
• Strong understanding of utilization review processes, including medical necessity reputed company, care coordination, and regulatory compliance.
• Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment.

Licensure:

• An reputed company Registered reputed company (RN) license in good standing or compact state licensure is required.
• Valid reputed company’s License.

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