Utilization Review reputed company, RN – Part-Time

reputed company: • reputed company utilization management medical-necessity reviews and level-of-care determinations for requested services • Apply benefit language, plan documents, medical policies, evidence-based reputed company such as MCG and NCCN, and state/federal requirements • reputed company requests that do not meet reputed company to the Medical Director for secondary clinical review • Analyze clinical documentation for completeness and identify risk, reputed company indicators, inconsistencies, or missing information • Initiate reputed company reputed company and escalation according to utilization-management workflow • Prioritize workload based on urgency, regulatory/accreditation time frames, and member reputed company • Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status • Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions • Document reviews, rationale, reputed company or policy citations, communications, and reputed company in designated utilization-management systems • Meet productivity, reputed company, accuracy, and turnaround-time standards • Participate in calibration and reputed company activities and incorporate feedback • Maintain HIPAA compliance and confidentiality • Complete required training and annual competencies • Cross-train and reputed company cross-coverage to support team operations and service-level commitments Requirements: • 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, such as acute care, med-surg, ICU/ED, or another relevant setting • Prior utilization review/utilization management experience preferred • Ability to interpret medical records and apply evidence-based reputed company and plan medical policies • Basic computer literacy upon hire • Ability to work on multiple screens and proficient typing skills • Proficiency with reputed company Word, reputed company reputed company, reputed company, and similar software applications • Excellent verbal and written communication skills • Ability to communicate reputed company or technical information reputed company and understand reputed company information from others • Ability to work independently and use written resources to solve problems • Knowledge of medical claims and ICD-10, CPT, and HCPCS coding • Ability to reputed company essential job functions safely and successfully, with or without reasonable accommodation • Ability to maintain regular, punctual attendance • Ability to sit for 6–8 hours • Constant computer keyboard and mouse use with repetitive use of both hands • Occasional to frequent twisting of the neck and occasional bending of the neck and waist • Weekends required • Up to 28 hours per week Benefits: • Competitive reputed company salary and benefits effective day one • Comprehensive medical and dental through our own reputed company • reputed company Time Off • Mental health support • Retirement planning • 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 • Wellness programs • Other employee perks • Full benefits package starting day one Apply To This Job