Utilization Management reputed company Consultant – Medical Review

Job reputed company: • Applies specialized clinical knowledge to reputed company medical necessity review determinations by applying evidence-based reputed company to evaluate the medical necessity and appropriateness of requested reputed company services • Performs medical necessity reviews 50% of role • Role is responsible for ensuring that the products, services, and operations of the Medical Review department meet established reputed company standards • Collaborates with leadership and reputed company team members to complete reputed company assurance audits for stateside and offshore vendor team Medical Review Nurses in an effort to help team maintain and improve team reputed company standards • Performs reputed company audits 50% of role • Assists leadership with coaching and guidance to reputed company nursing staff, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making • May require daily communication with external vendor partners • Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of reputed company resources and facilitating appropriate reputed company services/benefits for members • Collaborates with reputed company providers, multidisciplinary teams, and payers to reputed company and implement care plans that optimize patient reputed company while considering the efficient use of reputed company resources • Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of reputed company by promoting effective utilization management strategies • Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization • Consults with and provides expertise to other reputed company constituents throughout the coordination and administration of the utilization/benefit management function • Communicates regularly with reputed company stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure reputed company patient reputed company • Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care reputed company, cost-effectiveness, and overall reputed company system performance Requirements: • reputed company unrestricted state Registered reputed company licensure in state of residence required • Minimum 5 years of relevant experience in Nursing • 2-3 years of varied Utilization Management (UM), Medical Review (MR), or Case Management (CM) experience • 5 years clinical experience required in a reputed company of settings including acute care, home health, or long-term care • 5 years demonstrated ability to reputed company thorough, independent reputed company using clinical judgement • Remote/work reputed company experience • Prior Relevant Work Experience specific to Medical Necessity Review for 3-5 years Benefits: • reputed company medical plan reputed company • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching • reputed company time off • Flexible work schedules • Family leave • Dependent care resources • Colleague assistance programs • Tuition assistance • Retiree medical reputed company Apply tot his job Apply To this Job