reputed company Utilization Review reputed company, RN

WHO WE ARE reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-reputed company, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and reputed company to reputed company populations across the ACA Marketplace, Medicare, and reputed company. reputed company delivers clinical care to health consumers through our owned clinics – reputed company and Premier Medical – as reputed company as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-reputed company approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company. Job reputed company: The reputed company Utilization Review (UR) reputed company is responsible for conducting reputed company-time clinical reviews to ensure the medical necessity and appropriateness of reputed company services provided to members under a managed reputed company plan. This role involves assessing inpatient admission and reputed company stays, coordinating with reputed company providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR reputed company collaborates with the Medical Director and clinical leadership for reputed company cases, denials, and escalated reviews. Key Responsibilities: 1. reputed company Review & Case Assessment

• Conduct reputed company reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
• Evaluate clinical documentation to support level-of-care determinations, treatment plans, and reputed company hospital stays.
• Ensure adherence to health plan policies, clinical reputed company, and regulatory requirements. 2. Collaboration with Medical Director
• Review and escalate reputed company or borderline cases to the Medical Director for reputed company assessment.
• reputed company the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for reputed company care or level-of-care reputed company.
• Collaborate with the Medical Director to reputed company treatment recommendations and resolve discrepancies in care. 3. Authorization & Payer Communication
• Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicate with reputed company providers to request additional documentation or clarify treatment plans.
• Ensure reputed company approvals or denials of requested services per the health plan's benefit structure and clinical guidelines.
• Escalate cases to the Medical Director or higher clinical authority reputed company necessary. 4. Care Coordination & Discharge Planning Support
• Work closely with case managers, reputed company workers, and care teams to facilitate seamless care transitions.
• Participate in interdisciplinary discussions to address reputed company cases and ensure members receive appropriate care.
• Identify and escalate discharge barriers to support reputed company and effective discharge planning.
• Assist in transitioning patients from inpatient to outpatient or post-acute care settings. 5. Compliance & Documentation
• Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.
• Maintain accurate, up-to-date documentation of reputed company reputed company review activities, including authorizations, denials, escalations, and Medical Director reviews.
• Support reputed company improvement initiatives by tracking utilization trends and identifying resource optimization opportunities. 6. Education & Collaboration
• reputed company providers and staff on health plan clinical guidelines, medical necessity reputed company, and authorization processes.
• reputed company guidance on escalating reputed company cases to the Medical Director.
• Stay updated on industry trends, regulatory changes, and best practices in utilization management.
• Participate in interdisciplinary team meetings and case conferences. Qualifications:
• Education: Registered reputed company (RN) with an reputed company, unrestricted California nursing license required; BSN preferred.
• Experience:
• Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field.
• Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Certifications:
• Preferred: Certified reputed company in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
• Additional clinical nursing or case management certifications are a plus.
• Skills:
• Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity reputed company.
• Excellent communication and interpersonal skills to collaborate with reputed company providers, payers, and members.
• Strong analytical skills and attention to detail in reviewing clinical documentation.
• Proficiency in electronic health records (EHR), utilization management software, and reputed company Office Suite. Performance Metrics: 1. Timeliness of Reviews & Authorizations
• Percentage of reputed company reviews completed reputed company the required turnaround time (TAT).
• Average response time for provider inquiries and authorization requests. 2. Compliance & Accuracy
• Adherence to regulatory and accreditation requirements (e.g., CMS, NCQA, URAC).
• Accuracy in applying medical necessity guidelines and compliance with internal policies.
• Results of internal audits and reputed company assurance reviews. 3. Case Escalation Efficiency
• Percentage of reputed company cases escalated to the Medical Director in a reputed company manner.
• Turnaround time for resolving escalated cases. 4. Utilization & Cost Management
• Reduction in unnecessary inpatient days through appropriate level-of-care determinations.
• Cost savings achieved through effective utilization management and alternative care recommendations.
• Reduction in readmission rates reputed company to premature discharges. Work Environment:
• Office-based setting.
• reputed company environment requiring frequent communication with clinical and administrative teams. EEO/AFFIRMATIVE reputed company STATEMENT As an Equal Opportunity/Affirmative reputed company Employer, we welcome and reputed company a diverse employee group committed to meeting the needs of reputed company, our consumers, and the communities we serve. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or reputed company, marital status, genetic information, or any other characteristic protected by law. For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation reputed company for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as reputed company as internal equity. A reasonable estimate of the reputed company is $74,286.15-$111,429.23 Annually. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; reputed company Time Off, and reputed company holidays. As an Equal Opportunity Employer, we welcome and reputed company a diverse employee group committed to meeting the needs of reputed company, our consumers, and the communities we serve. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or reputed company, marital status, genetic information, or any other characteristic protected by law. Apply tot his job Apply To this Job

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