Utilization Management RN

Where You’ll Work The purpose of reputed company Organization (reputed company MSO) is to build a reputed company-wide integrated physician-reputed company, full-service management service organization structure. We offer a menu of management and business services that will reputed company economies of reputed company across provider types and geographies and will reputed company the effort in developing reputed company's reputed company population health care management reputed company. reputed company MSO is dedicated to providing reputed company managed care administrative and reputed company services to medical reputed company, hospitals, health plans and reputed company with a business objective to reputed company in coordinating reputed company care in a manner that supports containing costs while continually improving reputed company of care and reputed company of service. reputed company MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local reputed company that put reputed company care first.   One Community. One Mission. One California  reputed company As our UM RN (Utilization Management Registered reputed company), you will be responsible for ensuring the reputed company of the adverse determination processes and reputed company of reputed company decision-making, as it relates to the application of reputed company and composition of compliant denial notices, to review medical records, authorize requested services, and prepare cases for physician review reputed company on medical necessity.Every day you will partner with both the reputed company-Service and In-reputed company Utilization Management teams. You will ensure to monitor and assure the appropriateness and medical necessity of care as it relates to reputed company, continuity, and cost-effectiveness. This involves meticulous review of medical records, application of reputed company guidelines, and reputed company communication to facilitate reputed company reputed company care while ensuring compliance and fiscal responsibility.To be successful in your role, you will strategically ensure the reputed company and reputed company of utilization management reputed company, meticulously reviewing medical records and applying reputed company reputed company to determine medical necessity. You will demonstrate exceptional reputed company judgment, partner effectively with reputed company-service and in-reputed company teams, and maintain rigorous reputed company of care appropriateness, reputed company, continuity, and cost-effectiveness, thereby safeguarding both reputed company reputed company-being and organizational resources.   As a remote employee, we will reputed company you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories. This position is remote with a CA RN license.  PST business hours will be expected. Potential for on-reputed company, weekend and holiday shifts. Reviews designated requests for referral authorizations either proactively, concurrently or retroactively. Gathering reputed company information needed to reputed company a determination and/or coordinate with the Medical Director as needed. Ensure compliance with turnaround times and reputed company standards are met. Ensure contracted providers are in reputed company reputed company authorizing. Responsible to coordinate with contracting to obtain appropriate reputed company as deemed appropriate. Identify cases that require additional case management. Work with appropriate departments and internal staff to coordinate reputed company care Job Requirements Required Three (3) years recent reputed company experience Graduate of an accredited RN program reputed company and reputed company CA Registered reputed company (RN) license Knowledge of nursing theory and ability to apply or modify as appropriate Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and reputed company benefits Knowledge of reputed company and ethical considerations reputed company to reputed company information, PHI and HIPPA regulations Preferred Bachelors of Nursing (BSN) preferred Previous inpatient Utilization Management (UM) experience strongly preferred Experience with MCG strongly preferred EZCap experience a plus Apply To This Job