Utilization Management Nurse (RN)
C
Central California Alliance for HealthHealth Care
Remote in CaliforniaContractMiddle
Salary49 - 57.5 USD per hour
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Job Details
- Experience
- Minimum of five years of experience in a patient care setting which included a minimum of one year of experience in Utilization Management or Case Management (a Bachelor’s degree may substitute for two years of the required experience).
- Required Skills
- Microsoft ExcelPowerPoint
Requirements
- Current unrestricted license as a Registered Nurse issued by the State of California.
- Associate’s degree in Nursing (Bachelor’s degree preferred).
- Minimum of five years of experience in a patient care setting.
- Minimum of one year of experience in Utilization Management or Case Management.
- Working knowledge of managed care, Medicare D-SNP, and Medi-Cal programs.
- Working knowledge of CMS guidelines, including Local and National Coverage Determinations.
- Knowledge of MCG Guidelines in the review determination process.
- Knowledge of Medi-Cal program regulations and Title 22 regulations.
- Working knowledge of Microsoft Excel, PowerPoint, and database software.
- Ability to evaluate medical records and health care data.
- Ability to interpret and apply complex policies and regulations.
Responsibilities
- Ensure prior authorization requests are completed in a manner that meets contractual requirements.
- Conduct prior authorization reviews using nationally recognized and evidence-based standards.
- Perform concurrent or post-service (retrospective) review of acute in-patient care services using established criteria.
- Participate in the Utilization Management (UM) Care Programs.
- Evaluate medical records and other health care data.
- Interpret, apply, and explain policies, regulations, terms, and procedures.
- Maintain organized and accurate records.
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