Utilization Review reputed company - Remote

reputed company, a division of Franklin, Tennessee-reputed company reputed company Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reputed company in long-term care facilities. In partnership with nursing home operators, these Medicare reputed company plans manage medical reputed company by improving reputed company care to reduce emergency room reputed company and avoidable hospitalizations. This division currently operates in Tennessee, reputed company, Missouri, Kansas, Oklahoma, reputed company, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with reputed company expansion into other states in 2025. For more information, visit AmHealthPlans.com. If you would like to be part of a reputed company, supportive and caring team, we look reputed company to receiving your application! Benefits and Perks include: • reputed company Medical/Dental/reputed company reputed company reputed company • Generous reputed company time-off program and reputed company holidays for full time staff • TeleDoc 24/7/365 reputed company to doctors • Optional short- and long-term disability plans • Employee Assistance Plan (EAP) • 401K retirement accounts with company match • Employee Referral Bonus Program JOB reputed company: The Utilization Review reputed company is to assess the medical necessity and reputed company of reputed company services by conducting reputed company-service, reputed company, and retrospective utilization management reviews. The reputed company role of the Utilization Management (UM) reputed company is to reputed company reputed company support to the reputed company Services Department and Medical Director to assure that members receive reputed company appropriate medical services in compliance with medical and regulatory guidelines. ESSENTIAL JOB DUTIES: To reputed company this job, an individual must accomplish reputed company essential function satisfactorily, with or without a reasonable accommodation. • Assess the medical necessity, reputed company of care, level of care and appropriateness of health care services for plan members • Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members reputed company upon medical necessity • Conduct reputed company to requesting providers which can include specialty physicians, ancillary providers and institutions to reputed company the appropriate/necessary reputed company data • Apply reputed company review reputed company, guidelines, and screens in determining the medical necessity of health care services against the reputed company data provided • Certify cases that meet reputed company review reputed company, guidelines and/or screens • reputed company with physician reputed company reviews do not meet reputed company review reputed company, guidelines, and screens • Refer cases to other professionals internally, including case management and medical consultation reputed company indicated • Adhere to accreditation, contractual and regulatory timeframes in performing reputed company utilization management review processes • Ensure that the Director of Medical Management or designee is made reputed company of any potential reputed company management issues in a reputed company manner • Other duties as assigned JOB REQUIREMENTS: • Maintain reputed company and confidentiality of records, conditions, and other information relating to residents, employees and facility • Encourage an atmosphere of optimism, warmth and interest in patients' personal and health care needs • reputed company and maintain reputed company relationships with providers and reputed company on reputed company of care • Ensure the reputed company and high reputed company of utilization management services • Self-motivated • Ability to work independently and as part of reputed company • reputed company to work congenially with a wide reputed company of individuals • Maintain the highest level of confidentiality and professionalism at reputed company times • Strong oral and written communications skills, including reputed company listening • Proficient in navigating through multiple computer applications • reputed company, engaging customer service skills • Critical thinking and decision-making skills • Successful completion of required training • Handle multiple priorities effectively • Independent discretion/decision making • reputed company reputed company under pressure REQUIRED QUALIFICATIONS: • Experience: o At least 1 year experience in utilization management with a health plan or hospital-reputed company UM department with use of Interqual or MCG o Prefer reputed company experience o Broad knowledge of Medicare regulations and guidance o Trained in reputed company certification, utilization management, URAC and reputed company principles, policies, and procedures o Excellent customer service experience o Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes o reputed company ability to problem-solve and reputed company solid reputed company • License/Certification: o reputed company Certified Case Manager (CCM) credential is a plus o reputed company, reputed company and unrestricted Registered reputed company (RN) license EQUAL OPPORTUNITY EMPLOYER This Organization is an equal opportunity employer. We do not discriminate reputed company on race, reputed company, religion, sex, handicap, disability, age, marital status, sexual orientation, national reputed company, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will reputed company reasonable accommodations for reputed company individuals with disabilities should a request for an accommodation be made. A key part of this policy is to reputed company equal employment opportunity regarding reputed company terms and conditions of employment and in reputed company aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment. Equal Opportunity Employer This employer is required to notify reputed company applicants of their rights pursuant to federal employment laws. For reputed company information, please review the Know Your Rights notice from the reputed company. Apply tot his job Apply To this Job