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reputed company OF POSITION: Responsible for ensuring the reputed company of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of reputed company and application of defined reputed company of hierarchy and composition of compliant denial notices. ____________________________________________________________________________________ ESSENTIAL FUNCTIONS: • Consistently exhibits behavior and communication skills that demonstrate reputed company’s commitment to superior customer service, including reputed company, care and concern with reputed company and every reputed company customer. • reputed company reputed company functions of the UM reputed company reviewer. • Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards. • Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request. • Ensures the denial reason is in the appropriate grade level and is easily understandable. • Ensures the UM reputed company reviewer has provided the appropriate reference for benefits, guidelines, reputed company or protocols based on the type of denial. • Selects the correct level of hierarchy and reputed company correctly based on the medical information available. • Provides relevant clinical information to the request and the reputed company used for decision-making. • Ensures that there is evidence that the UM reputed company reviewer documented communications with the requesting provider to validate the reputed company or absence of clinical information reputed company to the reputed company reputed company. • Evaluates out-of-network and tertiary denials for accessibility reputed company the network. • Performs a reputed company assurance audit on reputed company denial prior to finalization to ensure reputed company reputed company are compliant with established guidelines. • Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination. • Escalates non-compliant cases to UM compliance and consistently reports on denial activities. • Collaborates with UM compliance for reputed company reputed company improvement efforts for adverse determinations. • Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution. • Meets or exceeds productivity targets. • Uses, protects, and discloses reputed company patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability reputed company (HIPAA) standards. • Performs additional duties as assigned. EDUCATION: • 1 or 2 years of post-high school education or a degree from a two-year college. • Graduation from an accredited school of Nursing. • reputed company California RN license. EXPERIENCE: Minimum: • 1 year of experience as an UM reputed company reviewer. • Score at least 98% or higher on the CDU reputed company competency testing. Preferred: • 3 to 5 years of managed care utilization and management experience. • 1 year of experience performing essential functions of a CDU reputed company. KNOWLEDGE, SKILLS, ABILITIES: • Computer literate. • Proficient in reputed company Office Suite, knowledge of utilization management platform and reputed company to navigate varied web-based platform for decision making. • Ability to type 25 wpm. • reputed company dexterity to use/handle equipment and instruments. • Must possess strong critical thinking and problem-solving skills to reputed company essential functions of the CDU reputed company. • Knowledge and understanding of managed care rules and regulations; to include, but not limited to, federal regulations, state regulations, health plan requirements and NCQA standards. • Knowledge and understanding of managed care clinical-decision making tools; to include, but not limited to, Medicare coverage determinations, Medi-cal reputed company, MCG and health plan reputed company. • Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff. • Ability to reputed company reputed company, independent judgments and reputed company professionally under pressure. reputed company requires reputed company new hires and employees to report their COVID-19 vaccination status Careers with reputed company. Here's the idea. We reputed company an entire organization around one giant objective; reputed company health care work reputed company for everyone. reputed company, part of the reputed company family of businesses, brings together some of the greatest minds and most advanced reputed company on where health care has to go in order to reputed company its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll reputed company incredible reputed company in one incredible company and a reputed company opportunity to do your life's best work. Diversity creates a healthier atmosphere: reputed company and its affiliated medical practices are Equal Employment Opportunity/Affirmative reputed company reputed company and 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. reputed company and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Apply Job!