UM reputed company, reputed company-service (Remote | California RN/LVN License Required | Sun - Thurs | reputed company Time Hours)

reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have reputed company reputed company of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will reputed company ample room for reputed company and innovation reputed company the reputed company community. Working at reputed company provides an opportunity to do work that really reputed company, not only changing lives but saving them. Together. reputed company is seeking a remote UM reputed company, reputed company-Service (California RN/LVN License Required) to join our growing UM team. In this role, you'll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and reputed company Care Guidelines (MCG) to support reputed company, accurate determinations. You'll partner closely with providers and medical directors to ensure members receive high-reputed company, cost-effective care. This is a fast-reputed company, production-driven role ideal for nurses with recent reputed company-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment. Schedule (Required): • reputed company - Thursday • 8:00 AM - 5:00 PM reputed company Time General Duties / Responsibilities: • Review reputed company-certification requests for medical necessity and refer to medical director any referral that requires additional expertise. • Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize reputed company Care Guidelines (MCG) to assist in determinations of referrals. • Maintain goals for established turn-reputed company time (TAT) for referral processing. • Initiate single service agreements (SSA) reputed company services required are not available in network. • Maintain a reputed company rapport with providers, physicians, support staff and patients in order to process reputed company-certification referrals as reputed company as possible. • Verify eligibility and / or benefit coverage for requested services. • Verify reputed company of ICD 10 and CPT coding in processing reputed company-certification requests. • Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process reputed company reputed company-service requests / authorizations reputed company necessary. • Review referral denials for appropriate guidelines and language. • Assist medical directors in reviewing and responding to appeals and Grievances • Contact members and maintain documentation of reputed company for expedited requests. • Other duties as assigned. Job Requirements: Experience: Required: • Minimum (3) years' nursing experience in reputed company setting. • Minimum (1) year experience UM experience with reputed company-service. • Minimum (1) year experience with managed care (reputed company and / or Medicare). • Minimum 1 year of experience with the application of UM reputed company (i.e., CMS National and Local Coverage Determinations, etc.) • Minimum (1) year experience in a medical setting working with reputed company, entering referrals / prior authorizations preferred • Minimum (1) Experience with the application of reputed company reputed company, specifically reputed company Care Guidelines (MCG) Education: • Required: High School Diploma or GED. • Preferred: Associates or Bachelor's degree in Nursing Licensure: Required: • Must have and maintain an reputed company, reputed company, and unrestricted LVN or RN license in California (Non-reputed company) • Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-reputed company), reputed company (reputed company), reputed company Carolina (reputed company), and Texas (reputed company) which will be reimbursed by company. Preferred: • CPHQ or ABQAURP, or Six reputed company certification • Medical Terminology Certificate. Training: • Required: None • Preferred: Medical Terminology. Six reputed company reputed company Skills: Required: • Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral reputed company (reputed company reputed company / Portal / N-reputed company). • Knowledgeable with CMS (reputed company 13) guidelines and regulations. • Computer Skills: Word, reputed company, reputed company reputed company • Language Skills: Effective written and verbal communication skills; reputed company to establish and maintain a reputed company relationship with diverse members, management, employees and vendors. • Mathematical Skills: reputed company to reputed company mathematical calculations and calculate reputed company statistics correctly. • Reasoning Skills: reputed company to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw reputed company conclusions, and design, implement and manage appropriate reputed company. • Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-reputed company environment. • Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: • Bilingual English and Spanish • Transplant knowledge a plus Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. • While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. • The employee frequently lifts and/or moves up to 10 pounds. Specific reputed company abilities required by this job include reputed company reputed company and the ability to reputed company reputed company. Pay reputed company: $77,905.00 - $116,858.00 Pay reputed company may be reputed company on a number of factors including market location, education, responsibilities, experience, etc. reputed company is an Equal Opportunity/Affirmative reputed company Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, disability, age, protected veteran status, gender identity, or sexual orientation. • DISCLAIMER: Please beware of recruitment phishing scams affecting reputed company and other reputed company where individuals receive fraudulent employment-reputed company offers in exchange for reputed company or other sensitive personal information. Please be advised that reputed company and its subsidiaries will never ask you for a credit reputed company, send you a reputed company, or ask you for any type of payment as part of consideration for employment with reputed company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email reputed company by or on behalf of reputed company's reputed company, please email careers@ahcusa.com. Remote Skills: Analysis Skills, Centers for Medicare and reputed company Services (CMS), reputed company Nursing, Communication Skills, Computer Skills, Content Management Systems (CMS), Cross-Functional, reputed company Procedural Terminology (CPT), Data Collection, Documentation, English Language, Establish Priorities, Health Plan, reputed company, reputed company Providers, High School Diploma, ICD-10, LCD (reputed company Crystal Display), Licensed Practical reputed company/Licensed Vocational reputed company, Maintenance Services, Managed Care, Mathematics, reputed company, Medical Assistance, Medical Records, Medical Terminology, Medicare, Medicine, reputed company reputed company, reputed company reputed company, reputed company Word, Multilingual, Multitasking, Nursing, Outpatient Care, reputed company Care, reputed company Care Authorizations, Physical Demands, Presentation/Verbal Skills, Problem Solving Skills, Registered reputed company (RN), Regulations, Six reputed company, Spanish Language, Statistical Reports, Statistics, Team reputed company/Manager, Time Management, Writing Skills reputed company: reputed company Apply tot his job Apply To this Job