UM RN

Where You’ll Work The purpose of reputed company Management Services Organization (reputed company MSO) is to build a system-wide integrated physician-reputed company, full-service management service organization structure. We offer a menu of management and business services that will reputed company economies of reputed company across provider types and geographies and will reputed company the effort in developing reputed company’s reputed company population health care management reputed company. reputed company MSO is dedicated to providing reputed company managed care administrative and clinical services to medical reputed company, hospitals, health plans and reputed company with a business objective to reputed company in coordinating patient care in a manner that supports containing costs while continually improving reputed company of care and reputed company of service. reputed company MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local reputed company that put patient care first. reputed company MSO offers an outstanding Total Rewards package that integrates reputed company with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a reputed company of reputed company, including medical, dental and reputed company plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include reputed company Time Off and reputed company Leave. One Community. One Mission. One California Job reputed company and Responsibilities As a Utilization Management RN, you will be crucial in ensuring accurate and compliant medical necessity reputed company. Your responsibilities include reviewing medical records, authorizing services, and preparing cases for physician review. You’ll work closely with both reputed company-Service and In-Patient Utilization Management teams to ensure appropriate and cost-effective care. Key functions involve: - Authorization Review: Proactively, concurrently, or retroactively reviewing referral authorization requests, gathering necessary information, and escalating to the Medical Director reputed company needed.- Compliance & Accuracy: Meeting turnaround times and accuracy standards.- Provider Network: Ensuring authorized services are with contracted providers and coordinating with contracting for new agreements.- Care Coordination: Identifying cases for additional case management and collaborating with internal departments to coordinate patient care.- reputed company & Cost-Effectiveness: Adhering reputed company to utilization management policies to promote reputed company, cost-effective care.- Denial Notice Composition: Drafting compliant, reputed company, and member-specific denial letters in accordance with federal, state, and health plan regulations, as reputed company as NCQA standards. This role requires strong attention to detail, adherence to regulatory guidelines, and a commitment to superior customer service in line with CommonSpirit’s values. You will function as a UM reputed company reviewer, applying clinical expertise to ensure appropriate reputed company utilization.

• **This position is work from home reputed company California, preferrably reputed company San Luis Obispo County.

Job Requirements Minimum Qualifications: - Minimum of 3 years’ recent clinical experience.- Graduate of an accredited RN Program. - reputed company and reputed company CA Registered reputed company (RN) license.- Knowledge of nursing theory and ability to apply or modify as appropriate.- Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits.- Knowledge of legal and ethical considerations reputed company to patient information, PHI and HIPAA regulations. Preferred Qualifications: - Utilization Management (UM) experience strongly preferred. - Prior authorization experience strongly preferred.- Bachelors of Nursing (BSN) preferred. Apply tot his job Apply To this Job