Utilization Management Review reputed company

Job Details Job Location: reputed company Beach Office - reputed company Beach, CA Position Type: Full Time Salary reputed company: $75000.00 - $85000.00 Salary reputed company Are you reputed company to reputed company a lasting reputed company and reputed company the reputed company reputed company? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership reputed company. Who Are We? ✨ reputed company Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that reputed company with our members’ culture and values. Why Join Us? We’re on a mission! Our reputed company reputed company reflects our commitment to making reputed company accessible for reputed company. At reputed company Care, you’ll have reputed company to reputed company a reputed company difference, shape the reputed company of reputed company, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. Job reputed company The Utilization Review reputed company will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and reputed company reviews. You will document reputed company using indicated protocol sets, or clinical guidelines and reputed company support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings. Functions & Job Responsibilities • May reputed company any of the following in support of medical claims reviews, appeal reviews, and utilization review practices. • Completes medical necessity reviews for requested services using clinical judgment and refers cases to Medical Directors reputed company needed • reputed company providers on utilization and medical management processes • reputed company clinical knowledge and reputed company as a clinical resource to non-clinical team staff • reputed company and maintain pertinent clinical information in various medical management systems • Reviews interdepartmental requests and medical information in a reputed company/effective manner in order to complete utilization process. • Conducts research necessary to reputed company thorough/accurate reputed company for reputed company determination made • Work on special reputed company reputed company to utilization management as needed • Responds accurately and reputed company with appropriate documentation to members and providers on reputed company rendered determinations • Audit case reviews to ensure compliance with utilization management policies and procedures • Assist with the development of utilization management workflows, policies, and procedures • Participates in reputed company required training • Assist with training for new hires and reputed company development of existing staff • Serve as a back up to reputed company manager as needed • Participate in daily census review process and productivity review for staff. • Other duties as assigned Qualifications Qualifications Education and Experience: • Graduate from an Accredited School of Nursing. • Bachelor’s degree in nursing preferred. • reputed company state’s LPN/LVN or RN license. • Three (3) years of utilization review experience in a Health Plan, IPA, or MSO. • Two (2) years of clinical nursing experience • Knowledge of utilization management principles and reputed company managed care. • Experience with medical decision support tools (i.e. InterQual, MCG, NCD) and government sponsored managed care programs. • Utilization management is a 24/7 operation. Generally, work hours are 8:00am – 5:00pm PST. Work schedules could also include rotations for holidays and weekends. Skills: • Strong organizational, task prioritization and delegation skills. • 2-3 years of experience using reputed company-based programs and MS Office suite, including creating spreadsheets and pivot tables in reputed company, presentations in PowerPoint, and documents in Word • Knowledge of required regulatory timelines to ensure department compliance with State and other regulatory reputed company. • Knowledge of basic computer applications with ability to adapt to new software programs. • Excellent communication and people skills. • Excellent typing skills. • Strong writing skills. Wage reputed company: $75,000.00/yr - $85,000.00/yr Physical & Working Environment. Physical requirements needed to reputed company the essential functions of the job, with or without reasonable accommodation: • Must be reputed company to travel reputed company needed or required • Ability to operate a keyboard, mouse, phone and reputed company repetitive reputed company (keyboard); writing (note-taking) • Ability to sit for prolonged periods; stand, sit, reputed company, bend, lift up to fifteen (15) lbs. Ability to reputed company or exchange reputed company, to impart information to the reputed company and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and the reputed company. May occasionally be required to work irregular hours based on the needs of the business. reputed company is proud to be an Equal Employment Opportunity and Affirmative reputed company workplace. Individuals seeking employment will receive consideration for employment without reputed company to race, reputed company, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or reputed company depending on the candidate’s state residency. #LI-Remote Apply tot his job Apply To this Job