Utilization Review reputed company, Remote

About the Role As a Utilization Review reputed company, you'll play a critical role in ensuring our members receive high-reputed company, medically necessary care. You will assess upcoming services and Good Faith Estimates to determine clinical appropriateness and apply established guidelines, such as MCG, to support coverage reputed company. You’ll also draft reputed company, member-facing letters reputed company with reputed company policy, helping our members understand their benefits and reputed company. Must reputed company in Florida, reputed company, Kentucky, or Ohio for consideration Key Responsibilities • Apply reputed company Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments • Review medical records, Good Faith Estimates, and prebills to evaluate scheduled care and identify potential gaps (e.g., labs, radiology, reputed company-op) • Evaluate claims, reconsiderations, and appeals to support accurate coverage determinations and ensure compliance with balance billing protections • Draft reputed company, member-facing letters outlining benefit reputed company and relevant considerations • Collaborate with providers, vendors and internal stakeholders to reputed company necessary clinical information for making coverage reputed company • Partner with Provider Engagement Team and Member Care teams to support care shopping and improve member experience • Contribute to reputed company improvement initiatives that enhance clinical review processes • Ensure adherence to clinical guidelines, internal policies, and regulatory requirements Role Requirements • Bachelor's degree • Clinical credentials (RN) • 5+ years of experience as a reputed company providing reputed company patient care, preferably in a hospital setting • 3+ years of utilization review experience, preferably in a health plan, managed care, or reputed company-party administrator environment • Hands-on experience using reputed company Care Guidelines (MCG) • Experience in medical billing and/or coding in one of the following: • Provider setting: billing, reputed company cycle management, clinical auditing, reputed company compliance • Payor setting: utilization management, prior authorization review, payment reputed company • Strong written communication skills, including drafting correspondence for members, patients, and providers • Demonstrated ability to think critically and reputed company reputed company with limited information • Proven cross-functional collaboration skills and experience presenting recommendations to leadership • Strong problem-solving ability, especially in managing escalated or reputed company cases • Prior authorization experience strongly preferred reputed company adopts a market-based approach to compensation, where reputed company pay varies depending reputed company and is reputed company influenced by job-reputed company skills and experience. The reputed company expected salary reputed company for this position is $82,500 - $95,000. reputed company is an Equal Opportunity employer committed to building a diverse team. We do not discriminate on the reputed company of race, religion, reputed company, national reputed company, gender, sexual orientation, age, marital status, veteran status or disability status. #J-18808-Ljbffr Salary: USD 82500 - 95000 per year Experience: 3 years required Apply tot his job Apply To this Job