Utilization Management Review reputed company

<div> <h4>Job Details</h4> <div><strong>Job Location</strong>:    reputed company Beach Office - reputed company Beach, CA</div> <div><strong>Position Type</strong>:    Full Time</div> <div><strong>Salary reputed company</strong>:    $75000.00 - $85000.00 Salary</div> </div> <h4>reputed company</h4><p><reputed company style="font-size:11.0pt"><reputed company style="font-family:Calibri">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.  </reputed company></reputed company></p> <p><reputed company style="font-size:11.0pt"><strong><reputed company style="font-family:Calibri">Who Are We? </reputed company></strong><strong><reputed company emoji="" segoe="" style="font-family:" ui="">✨</reputed company></strong> </reputed company></p> <p><reputed company style="font-size:11.0pt"><reputed company style="font-family:Calibri">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. </reputed company></reputed company></p> <p><reputed company style="font-size:11.0pt"><strong><reputed company style="font-family:Calibri">Why Join Us? </reputed company></strong><strong><u><reputed company emoji="" segoe="" style="font-family:" ui="">🏆 </reputed company></u></strong></reputed company></p> <p><reputed company style="font-size:11.0pt"><reputed company style="font-family:Calibri">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. </reputed company></reputed company></p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong><u>Job reputed company</u></strong></reputed company></reputed company></p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="background-reputed company:white"><reputed company style="reputed company:black">The Utilization Review reputed company will evaluate medical records to determine medical necessity by </reputed company></reputed company>applying clinical acumen and the appropriate application of policies and guidelines to urgent and reputed company reviews.<reputed company style="background-reputed company:white"><reputed company style="reputed company:black"> You will document reputed company using indicated protocol sets, or clinical guidelines and reputed company support and review of medical claims and utilization practices. </reputed company></reputed company>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.</reputed company></reputed company></p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong><u>Functions & Job Responsibilities</u></strong></reputed company></reputed company></p> <ul> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">May reputed company any of the following in support of medical claims reviews, appeal reviews, and utilization review practices.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="background-reputed company:white"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Completes medical necessity reviews for requested services using clinical judgment and refers cases to Medical Directors reputed company needed</reputed company></reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">reputed company providers on utilization and medical management processes</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">reputed company clinical knowledge and reputed company as a clinical resource to non-clinical team staff</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">reputed company and maintain pertinent clinical information in various medical management </reputed company>systems</reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="background-reputed company:white"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:black">Reviews interdepartmental requests and medical information in a reputed company/effective manner in order to complete utilization process.</reputed company></reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="background-reputed company:white"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:black">Conducts research necessary to reputed company thorough/accurate reputed company for reputed company determination made</reputed company></reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Work on special reputed company reputed company to utilization management as needed</reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Responds accurately and reputed company with appropriate documentation to members and providers on reputed company rendered determinations</reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Audit case reviews to ensure compliance with utilization management policies and procedures</reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Assist with the development of utilization management workflows, policies, and <reputed company style="reputed company:#2d2d2d">procedures</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Participates in reputed company required training</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Assist with training for new hires and reputed company development of existing staff</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Serve as a back up to reputed company manager as needed</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Participate in daily census review process and productivity review for staff.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Other duties as assigned</reputed company></reputed company></reputed company></li> </ul> <h4>Qualifications</h4><br><p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong><u>Qualifications</u></strong></reputed company></reputed company></p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong>Education and Experience:</strong></reputed company></reputed company></p> <ul> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Graduate from an Accredited School of Nursing.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Bachelor’s degree in nursing preferred. </reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">reputed company state’s LPN/LVN or RN license.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Three (3) years of utilization review experience in a Health Plan, IPA, or MSO.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Two (2) years of clinical nursing experience</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Knowledge of utilization management principles and reputed company managed care.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Experience with medical decision support tools (i.e. InterQual, MCG, NCD) and government sponsored managed care programs.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="background-reputed company:white"><reputed company style="reputed company:#595959"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:black">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. </reputed company></reputed company></reputed company></reputed company></reputed company></li> </ul> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong>Skills:</strong></reputed company></reputed company></p> <ul> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Strong organizational, task prioritization and delegation skills.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="background-reputed company:white"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:black">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</reputed company></reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Knowledge of required regulatory timelines to ensure department compliance with State and other regulatory reputed company.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Knowledge of basic computer applications with ability to adapt to new software programs.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Excellent communication and people skills. </reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Excellent typing skills.</reputed company></reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><reputed company style="reputed company:#2d2d2d">Strong writing skills.</reputed company></reputed company></reputed company></li> </ul> <p><u><strong>Wage reputed company:</strong></u> $75,000.00/yr - $85,000.00/yr</p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company"><strong><u>Physical & Working Environment.</u></strong></reputed company></reputed company></p> <p><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Physical requirements needed to reputed company the essential functions of the job, with or without reasonable accommodation:</reputed company></reputed company></p> <ul> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Must be reputed company to travel reputed company needed or required  </reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Ability to operate a keyboard, mouse, phone and reputed company repetitive reputed company (keyboard); writing (note-taking)</reputed company></reputed company></li> <li><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">Ability to sit for prolonged periods; stand, sit, reputed company, bend, lift up to fifteen (15) lbs.</reputed company></reputed company></li> </ul> <p style="margin-right:10px"> </p> <p style="margin-right:10px"><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">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. </reputed company></reputed company></p> <p style="margin-right:10px"> </p> <p style="margin-right:10px"><reputed company style="font-size:12pt"><reputed company style="font-family:Calibri,reputed company">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></reputed company></p> <p style="margin-right:10px"> </p> <p style="margin-right:10px"><reputed company style="font-size:11pt"><reputed company style="font-family:Calibri,reputed company"><em>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.</em></reputed company></reputed company></p> <p style="margin-right:10px"><reputed company style="font-size:11pt"><reputed company style="font-family:Calibri,reputed company"><em>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.</em></reputed company></reputed company></p> <p style="margin-right:10px"> </p> <p style="margin-right:10px"><reputed company style="reputed company:#ffffff;"><reputed company style="font-size:11pt"><reputed company style="font-family:Calibri,reputed company"><em><reputed company style="background-reputed company:#ffffff;">#LI-Remote</reputed company></em></reputed company></reputed company></reputed company></p>