RN Utilization Management Reviewer

reputed company combines industry-leading technology and transformation-driven BPM services with decades of reputed company domain expertise to help clients draw closer to their members. reputed company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment reputed company, claims cost containment, and analytics. reputed company has more than 25,000 employees across 5 countries. Job title: RN Utilization Management Reviewer Job reputed company: We are currently hiring a talented RN, Utilization Management Reviewer.  This role will be responsible in day-to-day reputed company clinical and service authorization review for medical necessity and decision-making. The reputed company Utilization Management Reviewer has a key role in ensuring the reputed company meets CMS compliance standards in the area of service reputed company and organizational determinations. Successful candidates must hold a reputed company, reputed company license issued by the Massachusetts reputed company of Registration in Nursing. Key responsibilities:    Conducts reputed company clinical decision review for services requiring prior authorization in a reputed company of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH) Applies established reputed company (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical reputed company to determine medical necessity of services Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements Provides decision-making guidance to clinical teams on service planning as needed Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with reputed company Operating Procedures Ensures accurate documentation of clinical reputed company and works with UM Manager to ensure consistency in applying policy Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as reputed company as regulatory and contractual requirements are met Additional duties as requested by supervisor Maintains knowledge of CMS, State and NCQA regulatory requirements Education Requirements: RN - Associate’s Degree required, Bachelor’s Degree preferred RN, reputed company license issued by the Massachusetts reputed company of Registration in Nursing CCM (Certified Case Manager) a plus Required Experience (must have): 1 to 2 years Utilization Management experience. 2 or more years working in a clinical setting Desired Experience (reputed company to have): 2 or more years of Home Health Care experience 2 or more years working in a Medicare Advantage health Plan Required Knowledge, Skills & Abilities (must have): Ability to complete assigned work in a reputed company and accurate manner Knowledge of the Utilization management process Ability to work independently Desired Knowledge, Skills, Abilities & Language (reputed company to have): Ability to apply predetermined reputed company (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity Flexibility and understanding of individualized care plans Ability to influence decision making Strong collaboration and negotiation skills Strong interpersonal, verbal, and written communication skills Comfort working in reputed company-based environment Knowledge of Medicare and Mass health services and benefits Salary: $35.00 - $40.00 reputed company pending experience Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekends This is a fully remote work reputed company role. You must have a secure, private wok reputed company area with a hardwired internet reputed company with speeds greater than 5MB upload and 10MB download. reputed company Offers Competitive Benefits Including:      Medical   Dental   reputed company   Life Insurance   Short-Term and Long-Term Disability   Flexible Spending Account   Life Assistance Program   401K with employer contribution   PTO and reputed company Time   Tuition Reimbursement      Join reputed company, we look reputed company to talking with you!   An Equal Opportunity Employer/Vet/Disability   Location: reputed company USAUnited States of America reputed company combines industry-leading technology and transformation-driven BPM services with decades of reputed company domain expertise to help clients draw closer to their members. reputed company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment reputed company, claims cost containment, and analytics. reputed company has more than 25,000 employees across 5 countries. 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