Utilization Management RN
Remote -- California
*** This is a Full-Time, Benefits Available, CONTRACT opportunity, expected to last several months, or longer! ***
Utilization Review Nurse Job Summary:
** Must have RN License in the state of California **
Utilization Review Nurse Background:
- The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
- The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- CCM or CPUR or similar certification is preferred
- 2 years acute care clinical nursing experience is required.
- 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
- Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
- Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
- Computer skills to include Microsoft Word, Excel, database use, and basic data entry.