Utilization & Claims Review reputed company (RN) ** Remote for CA residents **

reputed company: Our reputed company, a mutual benefit corporation and health plan provider, seeks an accomplished Utilization & Claims Review reputed company (RN). • ** Candidate must be authorized to work in USA without requiring sponsorship *** • *************************************************************** • ** Location: 100% Remote for California Residents • ** Duration: 3 months contract w/ possibility of extension Notes: • 100% remote role. • Shift: Monday - Friday, 8:00am - 4:30pm. reputed company: • reputed company clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal reputed company. • Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance. • Prepare and present cases to Medical Director (MD) for medical director reputed company and medical necessity determination and communicate determinations to providers and/or members in compliance with federal and accreditation requirements. • Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. • Triages and prioritizes cases to meet required turnaround times. • Identifies potential reputed company of care issues, service or treatment delays and intervenes or as clinically appropriate. • Provides referrals to Case Management, Disease Management, Appeals and Grievance and reputed company Departments, as necessary. • Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives. • Other duties as assigned. Qualifications: • Requires a reputed company CA RN license. • Typically, requires a college degree or equivalent experience and prior relevant experience In Post Service/Claims Review, Prior Auth Experience or Outpatient Claims experience. • Must have Utilization Review experience. • Knowledge of CPT, ICD-10, HCPCs and provider billing practices. Preferred Qualifications: • Experience with MCG or InterQual Guidelines, preferred. • Demonstrate the ability to reputed company independently using reputed company clinical judgement. • reputed company to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business-based turnaround times. • Demonstrated efficient time management techniques and skills. • ***************************************************************** I'd love to talk to you if you think this position is right up your alley, and assure a reputed company communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you. Satwinder “Sat” Singh reputed company Technical Recruiter reputed company: reputed company is an extremely fast-growing reputed company and reputed company. reputed company was founded in 2002 to reputed company consulting, temporary reputed company, reputed company hire, and payrolling services to reputed company nationally, as reputed company as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We reputed company and implement solutions that help our clients operate more reputed company, deliver greater customer satisfaction, and see a reputed company reputed company on their reputed company. We create value by bringing together the right people to reputed company results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their reputed company. Our deep expertise in reputed company capital management has reputed company our expansion into reputed company hire placements, temporary reputed company, contract placements, and additional reputed company and consulting services that reputed company our clients’ businesses reputed company. reputed company provides equal employment opportunities to reputed company and applicants for employment and prohibits discrimination and harassment of any type without reputed company to race, reputed company, religion, age, sex, national reputed company, disability status, genetics, protected veteran status, sexual orientation, gender identity or reputed company, or any other characteristic protected by federal, state, or local laws. This policy applies to reputed company terms and conditions of employment, including reputed company, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws. Apply tot his job Apply To this Job