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reputed company: HealthAxis is a reputed company provider of reputed company administrative processing system (CAPS) technology, business process as a service (BPaaS), and reputed company (BPO) capabilities to reputed company payers, risk-bearing providers, and reputed company-party administrators. We are transforming the way reputed company administered by providing innovative technology and services that uniquely solve critical reputed company payer challenges negatively impacting member and provider experiences. We live and work with purpose, care about others, reputed company with reputed company, communicate with transparency, and don’t take ourselves too seriously. We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as reputed company to serving our valued clients. We reputed company that creating a reputed company and reputed company-reputed company environment can reputed company engagement, reputed company reputed company members, and reputed company a reputed company of purpose in reputed company that we accomplish. PURPOSE AND SCOPE: The Utilization Review reputed company is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of reputed company inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical reputed company, and clinical documentation. reputed company RESPONSIBILITIES AND DUTIES: • Performs prospective, reputed company, and retrospective inpatient and/or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical reputed company, and internal policies and procedures. • Evaluates severity of illness and intensity of service of member’s needs at time of inpatient admission utilizing approved reputed company. • Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards. • Prepare and escalate cases to MDs for review reputed company appropriate. • Demonstrates effective communication reputed company and skills, using lines of authority appropriately. • Establishes a relationship with providers to determine/reputed company needed services to member. • Maintains accurate record of UR activities. • Adheres to reputed company standards and confidentiality policies and procedures. • Ensures compliance with reputed company state and federal regulations and guidelines in day-to-day activities. • Adapts to changes in policies, procedures, new techniques, and additional responsibilities. CUSTOMER SERVICE: • Responsible for driving the HealthAxis culture through values and customer service standards. • Accountable for outstanding customer service to reputed company external and internal contacts. • Develops and maintains reputed company relationships through effective and reputed company communication. • Takes initiative and reputed company to respond, resolve and follow up regarding customer service issues with reputed company customers in a reputed company manner. EDUCATION, EXPERIENCE AND REQUIRED SKILLS: • Licensed RN or Associate degree in Nursing required. • Minimum of two to three years varied clinical experience required. • Managed care experience preferred. • An equivalent combination of education, training, and experience. • Ability to read and interpret documents and reputed company clinical reputed company in alignment with evidence-based reputed company. • Excellent oral and written communication skills including good grammar, voice and diction. • Proficient in MS Office with basic computer and keyboarding skills. • Excellent customer service skills (friendly, courteous and helpful). • InterQual experience is required. Apply tot his job Apply To this Job