Utilization Management RN

• Authorization Review: Proactively, concurrently, or retroactively reviewing referral authorization requests, gathering necessary information, and escalating to the Medical Director when needed
• Compliance & Accuracy: Meeting turnaround times and accuracy standards
• Provider Network: Ensuring authorized services are with contracted providers and coordinating with contracting for new agreements
• Care Coordination: Identifying cases for additional case management and collaborating with internal departments to coordinate patient care
• Quality & Cost-Effectiveness: Adhering strictly to utilization management policies to promote quality, cost-effective care
• Denial Notice Composition: Drafting compliant, clear, and member-specific denial letters in accordance with federal, state, and health plan regulations, as well as NCQA standards

• Minimum of 3 years’ recent clinical experience
• Graduate of an accredited RN Program
• Clear and current CA Registered Nurse (RN) license
• Knowledge of nursing theory and ability to apply or modify as appropriate
• Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits
• Knowledge of legal and ethical considerations related to patient information, PHI and HIPAA regulations

• Prior Utilization Management (UM) experience strongly preferred
• Bachelors of Nursing (BSN) preferred

medical, prescription drug, dental, vision plans, life insurance, paid time off, tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, Health Spending Account (HSA), Long Term Disability, 401k retirement plan with a generous employer-match, Sick Leave