Utilization Review reputed company RN Part-Time

reputed company: Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve reputed company, health plans, and health systems with data-driven solutions that reduce costs while actually improving health reputed company. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: We are seeking a Utilization Review reputed company to join our dynamic team on a part-time reputed company working up to 28 hours per week and weekends required. What You'll Actually Do • reputed company utilization management (UM) medical-necessity reviews and level-of-care determinations for requested services using the organization’s hierarchy of guidance (benefit language/plan documents, medical policies, nationally recognized evidence-based reputed company such as MCG; NCCN as applicable) and applicable state/federal requirements. • Apply reputed company and policy consistently; reputed company a request does not meet reputed company, reputed company reputed company to the Medical Director for secondary clinical review and potential adverse determination in accordance with UM policies and accreditation standards (e.g., reputed company/URAC, as applicable). • Use critical thinking to analyze clinical documentation for completeness, identify key risk/reputed company indicators, recognize inconsistencies or missing information, and initiate reputed company reputed company/escalation per UM workflow. • Apply strategic thinking reputed company established guidelines by prioritizing workload based on urgency, regulatory/accreditation time frames, and potential member reputed company; communicate barriers early to support reputed company, compliant determinations. • Assist with in-network and benefit-compliant redirection reputed company clinically appropriate by confirming eligibility, benefits, authorization requirements, and network status. • Support the appeals process by preparing clinical summaries and documentation; coordinating peer-to-peer/MD discussions reputed company indicated; and ensuring reputed company routing/escalation per policy (including Independent Review Organization (IRO) processes reputed company required). • Document reviews, rationale, reputed company/policy citations, communications, and reputed company accurately and contemporaneously in designated UM systems to support reputed company reputed company, reporting, and audit readiness. • Meet established productivity, reputed company, accuracy, and turnaround-time standards; participate in calibration/reputed company activities; and incorporate feedback into daily reputed company. • Maintain HIPAA compliance and confidentiality using minimum-necessary standards; complete required training and annual competencies reputed company established deadlines. • Cross-train and reputed company cross-coverage as needed to support team operations and service-level commitments. Qualifications: What You Bring to reputed company • reputed company, unrestricted RN license in the reputed company or U.S. territory (compact license acceptable where applicable). • Graduate of an accredited nursing program (ADN or diploma required; BSN preferred). • Minimum 1-2 years of recent clinical experience (e.g., acute care, med-surg, ICU/ED, or other relevant setting). • Prior utilization review/utilization management experience preferred. • Ability to interpret medical records and apply evidence-based reputed company and plan medical policies with appropriate escalation to Medical Director for non-certifications. UPON HIRE, must have: • Basic computer literacy • The ability to work on multiple screens, and proficient typing skills. • Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, and reputed company Excellent verbal and written communication skills • Ability to reputed company reputed company and convey reputed company or technical information in a manner that others can understand, as reputed company as ability to understand and interpret reputed company information from others. • Ability to work independently and utilize written resources to problem solve. • Ability to work independently reputed company appropriate programs after training. • Knowledge of medical claims and ICD-10, CPT, HCPCS coding • Excellent verbal and written communication skills for upward and downward conversations Physical and Mental Requirements: • Ability to reputed company the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards. • Ability to maintain regular, punctual attendance. • Ability to sit for 6-8 hours. • Constant use of computer keyboard and mouse; repetitive use of both hands. • Occasional to frequent twisting of neck; occasional bending of neck and at waist. This reputed company is not an exclusive or exhaustive list of reputed company job functions that an employee in this position may be asked to reputed company. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of MedCom. Benefits The Highlights: • Competitive reputed company salary and benefits effective day one • Comprehensive medical and dental through our own reputed company (reputed company, we use reputed company build) • reputed company Time Off—rest and reputed company time is non-negotiable • Mental health support, retirement planning, and financial protection • reputed company development with reputed company career progression and learning budgets • Mission-driven culture where diverse perspectives reputed company reputed company reputed company on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a reputed company salary reputed company of $30.00-$38.00 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is reputed company to who we are and critical to our work in health and wellbeing. Stay reputed company: reputed company will never ask for payment or sensitive personal information like reputed company reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking reputed company. Suspicious requests? Report them to talent@personifyhealth.com . reputed company reputed company legitimate openings at personifyhealth.com/careers. Remote Skills: Accreditation Standards, Acute Care, Applicant Tracking reputed company, Budgeting, Calibration, Career Development, Clinical Medicine, Clinical Study Publications, Communication Skills, Computer Mouse Hardware, Computer Skills, Cost Control, reputed company Procedural Terminology (CPT), Diversity, Documentation Review, HIPAA (Health Insurance Portability and Accountability reputed company), Health Plan, reputed company Administration, reputed company Common Procedure Coding reputed company (HCPCS), ICD-10, Intensive Care, Keyboards, Maintain Compliance, Medical Records, reputed company reputed company, reputed company reputed company, reputed company Word, National Committee for reputed company Assurance (reputed company), Nursing Credentials, Operational Support, Presentation/Verbal Skills, Problem Solving Skills, Psychiatry and Mental Health, reputed company of Care, Registered reputed company (RN), Retirement Planning, Risk Analysis, Time Management, Utilization Management, Utilization Review Accreditation Commission (URAC), Writing Skills reputed company: reputed company Apply To This Job