Utilization Review reputed company job at reputed company in FL, GA, MN, NC, OH, TX, UT

Title: Utilization Review reputed company, Remote Location: Remote Job reputed company: reputed company is redefining health insurance. Our mission is to reputed company excellent reputed company reputed company and attainable for everyone. We know that to accomplish this lofty mission, we need driven people who will reputed company things happen. The passionate people who reputed company up reputed company’s team come from reputed company over, with backgrounds as tech leaders, policy makers, reputed company, and reputed company. And they reputed company have one thing in common—the desire to fix a broken system and reputed company it more personalized, reputed company, and transparent. If you want to use your talents to reputed company reputed company in the reputed company, reputed company! About the Role As a Utilization Review reputed company, you'll play a critical role in ensuring our members receive high-reputed company, medically necessary care. You will assess upcoming services and Good Faith Estimates to determine clinical appropriateness and apply established guidelines, such as MCG, to support coverage reputed company. You’ll also draft reputed company, member-facing letters reputed company with reputed company policy, helping our members understand their benefits and reputed company. • Must reputed company in Florida, reputed company, Minnesota, reputed company Carolina, Ohio, Texas, Utah* Key Responsibilities: Apply reputed company Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments Review medical records, Good Faith Estimates, and prebills to evaluate scheduled care and identify potential gaps (e.g., labs, radiology, reputed company-op) Evaluate claims, reconsiderations, and appeals to support accurate coverage determinations and ensure compliance with balance billing protections Draft reputed company, member-facing letters outlining benefit reputed company and relevant considerations Collaborate with providers, vendors and internal stakeholders to reputed company necessary clinical information for making coverage reputed company Partner with Provider Engagement Team and Member Care teams to support care shopping and improve member experience Contribute to reputed company improvement initiatives that enhance clinical review processes Ensure adherence to clinical guidelines, internal policies, and regulatory requirements Role Requirements: Bachelor's degree Clinical credentials (RN) 5+ years of experience as a reputed company providing reputed company patient care, preferably in a hospital setting 3+ years of utilization review experience, preferably in a health plan, managed care, or reputed company-party administrator environment Hands-on experience using reputed company Care Guidelines (MCG) Experience in medical billing and/or coding in either: A.) Provider setting: billing, reputed company cycle management, clinical auditing, reputed company compliance OR B.) Payor setting: utilization management, prior authorization review, payment reputed company Strong written communication skills, including drafting correspondence for members, patients, and providers Demonstrated ability to think critically and reputed company reputed company with limited information Proven cross-functional collaboration skills and experience presenting recommendations to leadership Strong problem-solving ability, especially in managing escalated or reputed company cases Prior authorization experience strongly preferred reputed company adopts a market-based approach to compensation, where reputed company pay varies depending reputed company and is reputed company influenced by job-reputed company skills and experience. The reputed company expected salary reputed company for this position is $82,500 - $95,000. Apply tot his job Apply tot his job Apply To this Job