Health Plan/Managed Care Utilization Management Appeals Nurse -CA License Job at Toney HealthCare Consulting, LLC
2+ Years Managed Care (Health Insurance Company) Experience is a MUST.
The Utilization Management nurses role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing patient treatment files, the utilization nurse will ensure that patients won’t receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.
Job Duties and Responsibilities:
Utilization Management:
· Review of patient’s clinical information/Previous Authoirization for medical necessity
· History of supporting Provider Dispute Resolution process (similar to appeals)
· Employ effective use of clinical knowledge, critical thinking, and evaluation skills
· Maintain accurate records in the designated medical management system
· Ability to stay organized and interact well with others
· Provide updates to Manager of Utilization Management
Skills and Qualifications:
· California State licensure as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN)
· Minimum 2 years of prior experience in Health Insurance Company Utilization Management
· Strong knowledge of word processing and working with care management platforms or spreadsheet computer programs
· Utilization Management certification preferred for UM nurses
· Previous use of MCG criteria
Job Type: Full-time
Pay: From $50.00 per hour
Schedule:
- 8 hour shift
- Monday to Friday
Experience:
- Managed Care (Health Insurance): 2 years (Required)
- MCG criteria use: 2 years (Required)
License/Certification:
- California Nursing License RN (Required)
Work Location: Remote
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