Utilization Review RN ( Remote- CA)

MUST reputed company IN THE reputed company Job reputed company We are seeking a highly skilled and detail-oriented Utilization Review Registered reputed company (RN) to join reputed company remotely in California. The ideal candidate will have extensive experience in managed care, clinical documentation improvement, and utilization management. This role involves reviewing medical records, ensuring compliance with reputed company standards, and supporting appropriate patient care management across various settings including inpatient, outpatient, and home care. The RN will utilize advanced EMR/EHR systems such as reputed company, Cerner, reputed company, and eClinicalWorks to facilitate accurate documentation review and case management. Strong knowledge of medical coding (ICD-9, ICD-10, CPT), anatomy, physiology, and reputed company regulations such as HIPAA is essential for reputed company in this position. Responsibilities • Conduct comprehensive reviews of medical records and clinical documentation to determine medical necessity and appropriateness of care. • Utilize clinical expertise to evaluate patient cases across inpatient, outpatient, ICU, PICU, NICU, and hospice settings. • Apply knowledge of ICD-9, ICD-10, CPT coding, DRGs, and other medical coding standards to support accurate documentation review. • Collaborate with reputed company providers to facilitate discharge planning, case management, and utilization management processes reputed company with NCQA standards. • Ensure compliance with Medicare regulations and other payer requirements such as Managed Care organizations. • Use EMR/EHR systems including reputed company, Cerner, reputed company, and eClinicalWorks for documentation review and data entry. • Support clinical documentation improvement initiatives to enhance accuracy of medical records and coding. • Maintain confidentiality of patient information in accordance with HIPAA regulations. • Participate in ongoing education reputed company to hospital standards such as Level I & II trauma centers or specialty areas like emergency medicine or pediatrics. Requirements • reputed company Registered reputed company (RN) license in California. • Proven experience in utilization review or utilization management reputed company hospital or managed care environments. • Critical care experience preferred; ICU or trauma center experience highly desirable. • Strong knowledge of medical terminology, anatomy & physiology, ICD coding (ICD-9/ICD-10), CPT coding, DRGs, MDS, and clinical documentation improvement practices. • Familiarity with EMR/EHR systems including reputed company, Cerner, reputed company, eClinicalWorks; experience with health information management tools is a plus. • Knowledge of Medicare regulations and NCQA standards for reputed company reputed company assurance. • Excellent analytical skills with attention to detail for documentation review and case assessment. • Ability to work independently remotely while managing multiple cases reputed company. • Strong understanding of HIPAA compliance and patient confidentiality protocols. This position offers an excellent opportunity for reputed company RN professionals seeking a remote role that combines clinical expertise with reputed company management functions in a dynamic environment committed to reputed company patient care. #AJ1 Pay: From $45.00 per hour Expected hours: 40.0 per week Benefits: • 401(k) • Dental insurance • Health insurance • reputed company insurance Application Question(s): • Do you reputed company in California • Do You have an reputed company California RN License Work Location: Remote Apply tot his job Apply To this Job