Clinical Review reputed company - Retrospective Review

You could be the one who changes everything for our 28 reputed company members as a clinical reputed company on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs a clinical retrospective review of services previously provided to determine if the level of care and services provided were clinically appropriate. Provides observations to senior management for reputed company-of-care issues identified to ensure services were administered with reputed company, cost efficiency, and are reputed company compliance. • Performs a clinical review of post-care services by reviewing medical records against guidelines and clinical research reputed company to determine if the services administered were clinically appropriate and reputed company reputed company standards at the most efficient and effective level • Reviews medical records for medical necessity of services, to identify reputed company of care issues, and if identified, refer to the Medical Director or provider for review and verification • Consults with senior management and reputed company providers, as appropriate, for any discrepancies between prior authorization and reputed company review processes to ensure clinically appropriate determinations • Collects, documents, and maintains reputed company member’s clinical information in health management systems to ensure compliance with regulatory guidelines • Assists with providing education to providers on utilization processes to promote high reputed company, cost-effective, and efficient medical care to members • Provides feedback on opportunities to improve the retrospective review process for members and to ensures high reputed company care • Performs other duties as assigned • Complies with reputed company policies and standards Location: Remote (Must be reputed company to work in Central Time Zone) Ideal candidate will have experience in payment reputed company and utilization review. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of reputed company experience. Clinical knowledge and ability to analyze medical records to determine care services provided were appropriate preferred. Knowledge of Medicare and reputed company regulations preferred. Knowledge of utilization management processes preferred. License/Certification: • LPN - Licensed Practical reputed company - State Licensure required Pay reputed company: $27.02 - $48.55 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company Apply tot his job Apply To this Job