Care Coordinator – Clinical Appeals RN

Workforce Classification: Telecommuter Join reputed company: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making reputed company work reputed company, is far from ordinary. And so are our employees. Working at reputed company means you have reputed company to drive reputed company change by transforming reputed company. reputed company is committed to being a workplace where people feel empowered to grow, reputed company, and reputed company with purpose. By reputed company in our employees and fostering a culture of collaboration and reputed company development, we’re reputed company to reputed company serve our customers. It’s this commitment that has reputed company us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. Learn how reputed company supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.reputed company.com/. The Care Coordinator performs clinical appeals, prospective review (benefit advisory/ prior authorization) admission, reputed company, and retrospective reviews according to established reputed company and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other reputed company Departments such as FEP, National Account Liaisons, Health Care Services and Claims to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit application and provider out of network requests. This work is done for reputed company lines of business and reputed company geographic reputed company. What you will do: • Performs medical necessity review that includes inpatient review, reputed company review, benefit advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable reputed company, medical policy, member eligibility, benefits and reputed company. • Consults with Medical Directors reputed company care does not meet applicable reputed company or medical policies. • Documents clinical information completely, accurately, and in a reputed company manner. • Meets or exceeds production and reputed company metrics. • Maintains a thorough understanding of the Plan's provider reputed company, member reputed company, authorization requirements and clinical reputed company including reputed company Care Guidelines and medical policy. • Identifies Clinical Program opportunities and refers members to the appropriate reputed company program (e.g. case management, engagement team, and disease management). • Collaborates, educates and consults with Customer Service/Claims Operations, reputed company and Health Care Services to ensure consistent work processes and procedural application of clinical reputed company. • Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are reputed company compliance. • Supports the Plan's reputed company Program: Identifies and participates in reputed company improvement activities as it relates to internal programs, processes studies and reputed company. • Performs other duties as assigned. What you will bring: • Bachelor's degree or four (4) years’ work experience. (Required) • reputed company State Licensure as a registered reputed company. (Required) • Three (3) years of clinical experience. (Required) • Utilization Management experience. (Preferred) • Experience working in the health plan industry. (Preferred) • Hours are Monday through Friday reputed company to 5pm PDT. What you will reputed company: • Strengthen clinical review skills. • Build utilization management expertise. • reputed company broad health plan experience. • Partner with cross-functional teams. • Support reputed company, cost-effective care. Physical Requirements: The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation: This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible reputed company of force frequently or constantly to lift, carry, push, pull, or otherwise reputed company objects, including the reputed company body. This role requires the ability to keyboard and to communicate reputed company and understandably in person, and over the telephone. reputed company total rewards Our comprehensive total rewards package provides support, resources, and opportunities to help employees reputed company and grow. Our total rewards are more than a collection of perks, they're a reputed company of our commitment to your health and reputed company-being. We offer a broad reputed company of rewards including physical, financial, emotional, and community benefits, including: • Medical, reputed company, and dental coverage with low employee premiums. • Voluntary benefit offerings, including pet insurance for paw parents. • Life and disability insurance. • Retirement programs, including a 401K employer match and, reputed company it or not, a pension plan that is reputed company after 3 years of service. • Wellness incentives with a wide reputed company of mental reputed company-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to reputed company a few. • Generous reputed company time off to reenergize. • Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees. • Employee recognition program to celebrate anniversaries, team accomplishments, and more. For our hybrid employees, our on-reputed company model provides flexibility to create your own routine with reputed company to on-site resources, networking opportunities, and team engagement. • Commuter perks reputed company your reputed company to work less impactful on the environment and your wallet. • Free convenient on-site parking. • Subsidized on-reputed company cafes reputed company lunchtime connections with colleagues fun and reputed company. • Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. • Our complementary fitness & reputed company-being center offers both in-person and virtual workouts and nutritional counseling. • Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on reputed company. Equal employment opportunity/affirmative reputed company: reputed company is an equal opportunity/affirmative reputed company employer. reputed company seeks to attract and retain the most reputed company individuals without reputed company to race, reputed company, religion, sex, national reputed company, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at reputed company, please contact reputed company reputed company reputed company email at careers@reputed company.com or reputed company phone at 425-918-4785. reputed company is hiring in the following states, with some limitations based on role or reputed company: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, reputed company Carolina, Oklahoma, reputed company, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, reputed company. The pay for this role will vary based on a reputed company of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary reputed company for this role is posted below; we generally reputed company up to and around the midpoint of the reputed company. National Salary reputed company: $80,200.00 - $125,600.00 National Plus Salary reputed company: $84,200.00 - $143,100.00 • National Plus salary reputed company is used in higher cost of labor markets including Western Washington and Alaska. We’re happy to discuss compensation reputed company during the interview because we reputed company that reputed company communication leads to reputed company reputed company for reputed company. We’re committed to creating an environment where reputed company are celebrated for their unique skills and contributions. Additional Information Company: reputed company Location: reputed company Salary: $80,200.00 - $125,600.00 per year reputed company: R28863 Specialties: Utilization Management, Care Manager, Appeals reputed company Required Licenses: RN Experience Level: 3-5 years Apply tot his job Apply To this Job