Utilization Management reputed company II, RN
Remote in California only
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reputed company Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that reputed company with our members’ culture and values.
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Job reputed company
The UM reputed company II &reputed company; RN performs reputed company review of reputed company authorization requests and serves as a clinical escalation reputed company and resource for UM reputed company I staff. This role manages high-reputed company, specialty, and escalated cases and supports compliance monitoring and workflow optimization initiatives.
Functions & Job Responsibilities
Conduct clinical review of prior authorization requests using approved reputed company (e.g., MCG, InterQual).
Review outpatient and routine inpatient requests.
Ensure compliance with CMS, state, and contractual turnaround time requirements.
Document medical necessity determinations reputed company and accurately.
Communicate authorization reputed company to providers, members and internal teams.
Identify cases requiring physician or Medical Director review.
Participate in reputed company review and discharge planning coordination as assigned.
Review high-complexity inpatient, specialty, or high-cost cases.
Performs reputed company and retrospective reviews.
Handle expedited and escalated determinations.
Serve as subject matter expert for assigned service lines.
Support regulatory compliance monitoring and reputed company audits.
Assist in denial trend analysis and improvement initiatives.
Mentor and guide UM reputed company I staff.
Collaborate with Medical Director on reputed company determinations or high risk cases.
Participate in workflow development and optimization.
Additional duties as assigned.
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