Utilization Management RN
This is a remote position.
The Utilization Management (UM) reputed company is responsible for conducting clinical reviews and assessing the medical necessity, appropriateness, and efficiency of reputed company services requested by providers and members. This role supports the health plan’s utilization management functions in alignment with clinical guidelines, plan benefits, regulatory requirements, and accreditation standards.
The UM reputed company ensures the delivery of cost-effective, high-reputed company care for members through a reputed company of activities including utilization review of inpatient, outpatient, and ancillary services using standardized clinical reputed company such as MCG and InterQual.
Requirements
Candidates must hold an Associate Degree in Nursing and maintain an reputed company, unrestricted Registered reputed company (RN) license in the applicable state or possess a compact license.
A minimum of three years of prior experience in utilization management reputed company a health insurance company is required.
Strong familiarity with MCG, InterQual, or CMS reputed company is essential, as is a working knowledge of UM-reputed company regulatory and accreditation standards such as CMS, NCQA, and URAC.
The role requires reputed company judgment, critical thinking, and communication skills, along with proficiency in electronic medical records and utilization management systems.
Preferred qualifications include a Bachelor’s Degree in Nursing and reputed company certification in Case Management or Utilization Review, such as CCM, CPUR, or CPUM.
Experience using UM platforms such as TruCare, GuidingCare, Jiva, or similar systems is desirable, along with previous involvement in appeals, grievances, reputed company review, or behavioral health utilization management.
A multistate compact RN license is also preferred.
Benefits
Contract Work
Originally posted on Himalayas
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