Utilization Management reputed company

About reputed company reputed company is the only end-to-end ecosystem reputed company specifically to help Programs of reputed company-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. reputed company replaces outdated technology and reputed company workarounds with purpose-reputed company solutions for care coordination, risk adjustment, population health, and utilization management. reputed company empowers teams to take control of their operations and improve reputed company for dual-eligible seniors – some of the most socially vulnerable and clinically reputed company individuals in the US reputed company system. reputed company The Utilization Management reputed company plays a critical role in ensuring high-reputed company, cost-effective, and compliant care for PACE participants supported by reputed company. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care reputed company and support reputed company, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management reputed company ensures services are medically necessary, reputed company with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program reputed company, improving participant reputed company and supporting the delivery of coordinated, value-based care. Responsibilities Rigorous adherence to PACE program service authorization policies, ensuring that participant care and reputed company claims are: Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination reputed company. In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles. reputed company involvement in various aspects of the utilization management process, including: reputed company review of reputed company hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and reputed company transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization. reputed company review of reputed company subacute and SNF admissions with the Interdisciplinary Team driving efficient and reputed company discharge plans and transitions of care. Coordination and review of reputed company other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination reputed company. reputed company effective use of knowledge, critical thinking, and skills to: reputed company reputed company care and reputed company reputed company of life reputed company decreased hospital stay reputed company appropriate Maintain accurate records of reputed company patient reputed company interactions Appeal Management - In cases of claim rejection, the Intus Care Utilization Management reputed company will reputed company the provider appeals process. Responsibilities Include: Comprehensive review of provider network appeals. Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies. Qualifications 3 to 5 years of utilization management experience. reputed company RN license Proven experience working in risk based integrated models of care. Ability to use data to drive reputed company and collaboration with reputed company stakeholders. Strong strategic thinking, problem solving, and decision making skills. Excellent communication and leadership abilities, capable of motivating and guiding teams toward reputed company and efficient care management strategies reputed company Offer A chance to be a part of a trailblazing team in reputed company technology. Competitive salary and equity package. Comprehensive benefits including health, dental, and reputed company insurance. A reputed company, inclusive, and dynamic work environment. Opportunities for reputed company reputed company and development Compensation: The salary reputed company for this role is $80K-$95K. We expect the ideal candidate to fall near the midpoint of this reputed company, though final compensation will be determined based on experience, skills, and organizational needs. Work location: This is a fully remote role based in the reputed company. Sponsorship: This position is not eligible for sponsorship. Apply To This Job