Utilization Review RN

Location: Orange, CA
Date Posted: 02-01-2019
Utilization Review RN - Managed Care
Orange, CA

** This is a full-time, benefits available, CONTRACT-TO-HIRE opportunity, expected to convert to permanent positions after an established time frame! **

Utilization Review Nurse Job Summary:
  • Review of referrals to determine approval, modification or denial of services. Assure that utilization of referrals is completed within the proper time frames as specified by ICE and department standards.
  • Use appropriate criteria and document reasoning in IDX notes. Critical thinking must be applied to each decision made. Ability to make independent decisions based on job knowledge or criteria.
  • Identification of out of area providers and non-covered benefits.
  • Ensure that correct supporting documentation is obtained to resolve referrals in a timely manner. Ensure the denial and appeal process is followed.
  • Assist with education to providers regarding non-covered benefits, use of contracted providers and ancillary services.
  • Consult with Medical Director for all possible denial of service and ensure required time-frame is sufficient for the Medical Director to make a decision in required time frame.
  • Assist with PMM's (claims review) daily and provide determination on approval or denial review for daily check run.
  • ‚ÄčIdentify and refer cases appropriately per policy, and documents referral in case file.
Utilization Review Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • Bachelor degree and/or a CCM or CPHM /CPUM/CPUR or similar certification is preferred
  • At least 2-3 years of acute care clinical nursing experience is required.
  • Requires 3 years 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 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.
410.885.4745 (CALL – TEXT – FAX)

Get Informed with CareNational.tv
Managed Care News and more!
Sign-Up for Job Alerts
this job portal is powered by CATS