Utilization Management Nurse Consultant-California License required

Job Duties Review clinical information for medical necessity determinations of provider service requests for the inpatient and outpatient services. Perform initial and ongoing reviews for inpatient admissions, level of care, observation, pre-service, concurrent review and discharge planning in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements. Process requests for prior authorization of outpatient services in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements. Conduct all medical necessity clinical reviews in Customer’s care management platform for full transparency and tracking of Nurse activities and performance measures. Participate in department meetings, training, and audit activities equal to Customer employees. Role/Education Requirements Active California RN License Minimum of 2 years of recent health plan experience. High level of expertise in UM services Experience with MediCal and LA Country procedures and policies (preferred but not required) Experience with MCG Criteria (preferred but not required) Role Details Job Type: Contract Standard PST business hours, Monday through Friday Evenings, weekends or holiday coverage, as needed Work Location: Remote Pay: $75,491.75 - $90,914.79 per year Experience: • Health Plan UM: 3 years (Required) • MCG and/or Interqual: 1 year (Required) License/Certification: • California RN License (Required) Work Location: Remote Apply tot his job Apply To this Job