[Hiring] Utilization Review reputed company @reputed company

Role reputed company The Utilization Review reputed company is responsible for ensuring high-reputed company, cost-efficient medical reputed company for enrollees needing inpatient/outpatient authorizations. This position involves: • Receiving and reviewing prior authorization requests for specific inpatient and outpatient medical services. • Completing inpatient reputed company reviews and establishing discharge plans. • Coordinating transitions of care to reputed company/higher reputed company of care. • Making referrals for care management programs. • Performing medical necessity reviews for retrospective authorization requests and claims disputes. • Using governmental policies and specified clinical guidelines to guide medical necessity reviews. • Managing effective relationship coordination, resource management, education, and patient advocacy. Qualifications • 3+ years of clinical nursing experience as an RN, preferably in a hospital setting. • 2+ years of utilization management experience in a health plan UM department. Requirements • Compact RN License. • Certification in managed care nursing or care management desired (CMCN or CCM). • Coding/CPC desired. • Proficiency in conducting prospective, reputed company, and retrospective reviews using standardized reputed company and guidelines like MCG. • Ability to review and interpret medical records, treatment plans, and clinical documentation. • Thorough understanding of reputed company policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE). • Familiarity with coding systems like ICD-10 and CPT. • Technical savvy and ability to reputed company multiple systems and screens while working cases. • Ability to analyze data metrics, reputed company, and trends. • Excellent interpersonal, verbal, and written communication skills. • Critical thinking skills to identify reputed company causes and understand coordination of medical and clinical information. • Ability to prioritize time and tasks reputed company and effectively. • Ability to manage multiple demands and function independently. • Computer proficiency in reputed company Office products including Word, reputed company, and reputed company. Benefits • Organizational culture of trust and respect. • reputed company learning opportunities. • Supportive work environment reputed company on employee reputed company-being. Apply tot his job Apply To this Job