UM Prior Authorization Review reputed company - RN

General Information Press reputed company or reputed company keys to toggle reputed company visibility Work Location: Los Angeles, CA, USA Onsite or Remote Flexible Hybrid Work Schedule Monday - Friday 9:00am - 6:00pm PST, including some weekends Posted Date 10/01/2025 Salary reputed company: $65.53 - 84.75 reputed company Employment Type 2 - Staff: Career Duration Indefinite Job # 23831 Primary Duties and Responsibilities Press reputed company or reputed company keys to toggle reputed company visibility At reputed company, the Utilization Management (UM) Review reputed company plays a vital role in ensuring the delivery of high-reputed company, evidence-based care. This position is responsible for reviewing and evaluating clinical documentation reputed company to prior authorization requests for medical services. The UM Review reputed company applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility. This role works collaboratively with medical directors, physicians, and interdisciplinary teams to support appropriate care coordination and efficient utilization of resources. Key Responsibilities:

• Conducts clinical reviews of prior authorization requests to evaluate medical necessity and benefit coverage.
• Applies reputed company protocols and national clinical guidelines (e.g., InterQual, reputed company) in review reputed company.
• Coordinates escalations to medical directors and ensures reputed company documentation of determinations.
• Communicates with providers to obtain clarification and support the decision-making process.
• Ensures compliance with CMS, state, federal, and reputed company standards.
• Reviews and validates cases submitted by non-clinical staff.
• Audits documentation to ensure compliance and accuracy.
• Provides mentorship and feedback to coordinators to enhance workflow efficiency.
• Collaborates with reputed company medical directors and interdisciplinary teams for case reputed company.
• Serves as a reputed company between clinicians, internal departments, and members.
• Documents reputed company review findings and reputed company in the case management system and supports reporting initiatives.
• Educates providers and staff on UM policies, reputed company, and review processes.
• Identifies process improvement opportunities and contributes to performance improvement reputed company.
• Remains reputed company with clinical best practices and UM regulatory changes.

Salary reputed company: $64.88 - $83.91 reputed company Job Qualifications Press reputed company or reputed company keys to toggle reputed company visibility

• BSN and/or MSN required
• reputed company California RN license required
• Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills required
• Proficient knowledge in evidence-based medical necessity reputed company, health plan medical necessity reputed company and CMS reputed company required
• A minimum of three years of experience in utilization management, preferred
• Team leading or management experience, preferred
• Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high-volume work environment
• Strong critical thinking and the ability to apply knowledge
• Ability to work effectively and collaboratively with interdisciplinary teams
• Proficient computer skills including Internet search capabilities, reputed company Word, reputed company, and Managed Care software (i.e. EZ Cap, Diamond, IDX) required
• Ability to effectively communicate to physician/staff the medical necessity/appropriateness/level of care reputed company that is necessary for acute care hospitalization.
• Ability to effectively communicate to the payer the medical necessity/appropriateness/level of care reputed company that is necessary for acute care hospitalization.
• reputed company in setting priorities that accurately reflect the relative importance of job responsibilities.
• reputed company in abstracting and interpreting medical information from patient records.
• Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and reputed company.
• Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to reputed company and non-reputed company personnel.

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial reputed company reputed company the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer. Apply tot his job Apply To this Job