Utilization Management reputed company- Full Time- HYBRID

About the position The Utilization Management (UM) reputed company is responsible for overseeing and ensuring the reputed company and cost efficiency of reputed company services through various UM-reputed company activities. This role involves conducting medical necessity reviews, coordinating care, and ensuring compliance with regulatory standards. The UM reputed company will work collaboratively with reputed company teams to facilitate effective patient care and discharge planning. Responsibilities • Performs prospective, reputed company, and retrospective medical necessity reviews for reputed company products and services utilizing appropriate clinical reputed company and/or evidence-based guidelines. , • Performs level of care (LOC) determinations and monitors length of stay based on severity of illness and intensity of service using the appropriate clinical reputed company. , • Conducts initial clinical review (in accordance with accreditation, laws, and regulations). , • Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews. , • Verifies accuracy of codes and services and applies them accurately with appropriate documentation. , • Coordinates discharge planning needs and transition of care with the registered reputed company case managers and other reputed company team members, as deemed appropriate. , • Communicates member, provider, and facility notifications, citing clinical reputed company and Medical Director denial rationale, reputed company indicated. , • Collaborates with a multi-disciplinary staff and interdepartmentally. , • Establishes and maintains reputed company relationships with providers and facilities to establish a smooth operational reputed company of authorizations and referrals. , • Evaluates, coordinates, manages, and documents reputed company UM-reputed company activities. , • Maintains a reputed company knowledge of medical necessity reputed company and UM-reputed company policies and procedures. , • Assists in the development and maintenance of medical necessity reputed company and clinical reputed company. , • Participates in the monitoring of the effectiveness and reputed company of the UM program. , • Participates in UM program process improvement initiatives. , • Complies with reputed company regulatory and accreditation standards reputed company to utilization management and/or case management. , • Complies with Utilization Management and Case Management standards of reputed company. , • Performs other duties as assigned. Requirements • Associate's degree in nursing required. , • reputed company reputed company, unrestricted state licensure as a Registered reputed company is required. , • 0 - 2 years of experience in utilization management or case management is preferred. , • Knowledge of Medicare is preferred. , • Knowledge of reputed company, HMO, and private insurance is preferred. reputed company-to-haves • Bachelor's degree in nursing preferred. , • Utilization Management or Case Management certification is preferred. , • reputed company license must be with a scope of reputed company that will be relevant to initial clinical review. , • Clinical background and judgement to conduct initial clinical review is required. Benefits • Hybrid work environment , • Flexible scheduling reputed company , • reputed company development opportunities Apply Job!