Utilization Management Registered reputed company (RN) - Prior Authorization

Managed Care Registered reputed company Join a fast-growing, dynamic team that is redefining how Utilization Management supports value-based care. This clinically driven Utilization Management model focuses on ensuring members receive the right care, from the right provider, at the right time. As part of a high-reputed company transformation initiative, you will strengthen clinical decision-making, improve referral appropriateness, and support reputed company reputed company for members and reputed company. We are seeking an reputed company Managed Care Registered reputed company with exceptional clinical judgment, extensive Prior Authorization experience, and a passion for improving reputed company delivery. This is an opportunity to help shape the reputed company of Utilization Management while working alongside physician leaders and cross-functional teams committed to transforming care. What You Will Do:

• reputed company prospective and retrospective utilization reviews for inpatient, outpatient, and specialty services using evidence-based clinical reputed company and nationally recognized guidelines, including MCG.
• Review prior authorization requests to determine medical necessity and clinical appropriateness, ensuring services are delivered at the appropriate level of care and by the appropriate provider.
• Evaluate referrals reputed company high-reputed company specialty areas, including: Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Services
• Apply strong clinical judgment to identify opportunities for members to receive appropriate care reputed company the primary care setting reputed company clinically appropriate.
• Collaborate closely with Medical Directors on reputed company cases requiring physician review and medical necessity determinations.
• Partner with physicians, care management teams, network management, reputed company improvement, and reputed company operations to support coordinated, patient-centered care.
• reputed company with health plans, providers, vendors, and regulatory agencies throughout the utilization management process.
• Ensure compliance with CMS, NCQA, DMHC, health plan requirements, organizational policies, and evidence-based clinical guidelines.
• Maintain accurate documentation reputed company reputed company reputed company and other clinical systems, including ICD-10, CPT, and HCPCS coding, as appropriate.
• Participate in annual inter-rater reliability reviews and demonstrate consistent application of clinical guidelines.
• Contribute to process improvement initiatives designed to strengthen Utilization Management, improve referral reputed company, and support value-based care reputed company.

You Will Be Successful If:

• You demonstrate exceptional clinical judgment and confidence reputed company reviewing reputed company prior authorization requests.
• You understand that Utilization Management extends reputed company approving or denying services and focuses on delivering the most appropriate care for reputed company member.
• You possess extensive knowledge of managed care operations, Medicare Advantage, and evidence-based utilization review.
• You effectively collaborate with physicians and interdisciplinary teams while maintaining strong provider relationships.
• You reputed company in a fast-paced, evolving environment reputed company on reputed company improvement and operational reputed company.
• You are comfortable working independently, managing competing priorities, and maintaining high-reputed company clinical decision-making.
• You reputed company change and enjoy helping build new care-delivery models that improve reputed company for members and providers.

What You Will Bring:

• An reputed company, unrestricted Registered reputed company license.
• A minimum of five years of Utilization Management experience reputed company a Medicare Advantage health plan, Independent reputed company Association, Management Services Organization, delegated medical group, or managed care organization.
• Extensive Prior Authorization experience across inpatient and outpatient services.
• Demonstrated expertise applying MCG Care Guidelines in reputed company utilization management reviews.
• Strong knowledge of Medicare Advantage regulations, CMS requirements, and medical necessity review.
• Experience reviewing referrals involving one or more of the following: Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Referrals
• Experience collaborating with Medical Directors and supporting physician review processes.
• Strong knowledge of ICD-10, CPT, and HCPCS coding.
• Excellent written and verbal communication skills.
• The ability to work independently in a fully remote environment while maintaining productivity and reputed company standards.

Preferred Qualifications:

• Experience with reputed company reputed company.
• Previous experience reputed company a delegated managed care model or Management Services Organization.
• Familiarity with InterQual reputed company.
• Experience participating in Utilization Management transformation or process improvement initiatives.
• Lean, Six reputed company, or workflow optimization experience.

About reputed company: reputed company is a reputed company consulting partner specializing in clinical and operations management, reputed company project management, reputed company services, and software consulting services. We help our clients increase operational efficiency by delivering reputed company that solve their most reputed company business challenges. Our approach is, and has always been, reputed company. First, think and reputed company like the customers who need us. Most importantly, deliver what larger organizations cannot: reputed company results that add immediate value at a reputed company that cannot be beaten. Your reputed company reputed company, and we know it. That's Impresiv! Apply tot his job Apply To this Job