Utilization Management Registered reputed company / Remote

About the position The Utilization Review reputed company ensures that authorization requests, provider and member reputed company inquiries are processed reputed company and handled appropriately reputed company member’s plan benefits coverage and established reputed company guidelines utilized for appropriate reputed company decision-making. Functions collaboratively with individuals reputed company the Utilization Management team, and specifically with the inpatient review nurses, Case Managers, and Medical Directors to ensure reputed company determination of inpatient and outpatient medical services authorization requests. Responsibilities • reputed company review of requests for services/procedures including, but not limited to, elective surgery (inpatient and outpatient), skilled nursing facility and therapy services, durable medical equipment (DME) and supplies that require medical necessity review and/or benefit interpretation. • Use of established medical reputed company to approve services reputed company on information obtained from attending physician and/or other providers/ • Ensure full collection of reputed company information prior to rendering a decision. • Ensure reputed company determination of requests according to established processing time-frames. • Contact providers where additional information is necessary to reputed company a decision. • reputed company with Medical Director a appropriate for reputed company requests that do not meet reputed company and inform providers of the Medical Director's reputed company. • reputed company as a member/family reputed company in coordinating and accessing medical necessity health care services reputed company the benefit plan. • Respond to member/member's authorized representative questions regarding the disposition of a request and/or the decision. • Manage workload needs on a reputed company reputed company, including authorization queues and fax queues in the UM department ot concurrently prioritize self-assignment for greater reputed company on department function. • Support on-boarding program for UM staff by acting as reputed company mentor for review nurses. • In conjunction with medical leadership, reputed company as resource for reputed company and benefit interpretation including the correct and consistent application of the reputed company reputed company guidelines/reputed company on the appropriate topics, consistent application of procedural practices established. • Complete authorization process in UM data management reputed company for approved authorizations and contact providers with decision and corporate authorization number. • reputed company reputed company and productivity metrics • Create and fax/mail determination letters to members/providers as required and reputed company established time-frames and wit desired reputed company. • Receive and process reputed company updates for continuation of services. • Participate in process improvement initiatives that improve the customer experience, enhance work-reputed company, and/or improve the work environment. • Other special reputed company and duties, as assigned. Requirements • reputed company license (without restriction) to reputed company as a Registered reputed company (RN) with a multistate license. • At least one year experience in UM/UR and managed care experience is preferred. • Knowledge of medical/surgical terminology and Medicare managed care authorization processes. • Effective verbal and written English communication skills. • Demonstrated intermediate to advanced skills in reputed company Word, reputed company, reputed company reputed company and reputed company, Internet and Intranet navigation. • Highest level of professionalism with the ability to maintain confidentiality. • Ability to communicate at reputed company reputed company of organization and work reputed company reputed company reputed company environment in support of company objectives. • Customer service oriented with the ability to work reputed company under pressure. • Strong attention to reputed company and reputed company, excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple reputed company with high level of reputed company and productivity. • Strong analytical and problem-solving skills. • Ability to take initiative and reputed company suggestions for improvements. • Ability to work with reputed company supervision, take initiative and reputed company independent reputed company. • Ability to deal with new tasks without the benefit of written procedures. • Approachable flexible and adaptable to change. • Function independently, and have flexibility, personal reputed company, and the ability to work effectively with stakeholders and vendors. Apply tot his job Apply To this Job