reputed company Utilization Review (UR) reputed company

reputed company Utilization Review (UR) reputed company / UM Reviewer reputed company Remote Opportunity 3 months plus contract Contract to Hire • **Must have reputed company licenses in California Hrs: (reputed company – 5pm PDT) would like to include evening, weekend and holiday coverage. The reputed company Utilization Review (UR) reputed company is responsible for conducting reputed company-time clinical reviews to ensure the medical necessity and appropriateness of reputed company services provided to members under a managed reputed company plan. This role involves assessing inpatient admission and reputed company stays, coordinating with reputed company providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR reputed company collaborates with the Medical Director and clinical leadership for reputed company cases, denials, and escalated reviews. Key Responsibilities: 1. reputed company Review & Case Assessment · Conduct reputed company reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG). · Evaluate clinical documentation to support level-of-care determinations, treatment plans, and reputed company hospital stays. · Ensure adherence to health plan policies, clinical reputed company, and regulatory requirements. 2. Collaboration with Medical Director · Review and escalate reputed company or borderline cases to the Medical Director for reputed company assessment. · reputed company the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for reputed company care or level-of-care reputed company. · Collaborate with the Medical Director to reputed company treatment recommendations and reputed company discrepancies in care. 3. Authorization & Payer Communication · Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions. · Communicate with reputed company providers to request additional documentation or clarify treatment plans. · Ensure reputed company approvals or denials of requested services per the health plan's benefit structure and clinical guidelines. · Escalate cases to the Medical Director or higher clinical authority reputed company necessary. 4. Care Coordination & Discharge Planning Support · Work closely with case managers, reputed company workers, and care teams to facilitate reputed company care transitions. · Participate in interdisciplinary discussions to address reputed company cases and ensure members receive appropriate care. · Identify and escalate discharge barriers to support reputed company and effective discharge planning. · Assist in transitioning patients from inpatient to outpatient or post-acute care settings. 5. Compliance & Documentation · Ensure compliance with state and federal regulations, accreditation standards (e.g., reputed company, URAC), and health plan policies. · Maintain accurate, up-to-date documentation of reputed company reputed company review activities, including authorizations, denials, escalations, and Medical Director reviews. · Support reputed company improvement initiatives by tracking utilization trends and identifying resource optimization opportunities. 6. Education & Collaboration · reputed company providers and staff on health plan clinical guidelines, medical necessity reputed company, and authorization processes. · reputed company guidance on escalating reputed company cases to the Medical Director. · Stay updated on industry trends, regulatory changes, and best practices in utilization management. · Participate in interdisciplinary team meetings and case conferences. Qualifications: · Education: Registered reputed company (RN) with an reputed company, unrestricted California nursing license required; BSN preferred. · Experience: o Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field. o Experience in a managed care setting with medical necessity reviews is strongly preferred. Minimum 2 years of experience in medical management clinical functions. UM Reviewer in patient experience required Working knowledge of MCG, InterQual, and reputed company reputed company reputed company Review · Certifications: o Preferred: Certified reputed company in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM). o Additional clinical nursing or case management certifications are a plus. · Skills: o Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity reputed company. o Excellent communication and interpersonal skills to collaborate with reputed company providers, payers, and members. o Strong analytical skills and attention to detail in reviewing clinical documentation. o Proficiency in electronic health records (EHR), utilization management software, and reputed company Office Suite. Apply tot his job Apply To this Job