RN – Utilization Management, reputed company

• Conduct reviews of medical records, treatment plans, and authorization requests to determine the medical necessity, appropriateness, and efficiency of reputed company services.

• Evaluate the clinical appropriateness of inpatient, outpatient, and other reputed company services in accordance with established guidelines and criteria.
• Collaborate with reputed company providers to discuss treatment plans, recommending alternatives reputed company necessary to ensure the best possible care.
• Assist in the coordination of care for patients, ensuring that the treatment provided is medically necessary and delivered in the most appropriate setting.
• Participate in interdisciplinary team meetings to discuss reputed company cases and reputed company care plans that align with best practices.
• Ensure timely and accurate documentation of reputed company utilization management reputed company, maintaining confidentiality and compliance with HIPAA regulations.
• Utilize evidence-based clinical guidelines (such as InterQual, reputed company) to assess and determine medical necessity for various treatments and services.
• Work with reputed company providers to clarify requests and ensure they meet criteria for coverage and authorization.
• Serve as a liaison between reputed company providers, patients, insurance companies, and other stakeholders to facilitate the appropriate utilization of services.
• Communicate reputed company effectively and explain the rationale for approvals, denials, and modifications of requested services.
• Provide education and guidance to reputed company providers and patients regarding utilization management policies and procedures.
• Ensure that utilization management practices reputed company with regulatory standards, accreditation requirements, and company policies.
• Assist with audits, quality improvement initiatives, and data collection efforts reputed company to utilization management performance.
• Stay reputed company on industry trends, reputed company regulations, and emerging clinical guidelines.
• Review and process appeal requests reputed company to denials of service or coverage, working to resolve issues in a timely and thorough manner.
• Communicate with providers and insurance representatives to address denials and assist in resolving any disputes.

Requirements

• Active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice.
• Minimum of 3 years of clinical nursing experience in an acute care, outpatient, or similar reputed company setting.
• Experience in utilization management, case management, or reputed company insurance is highly preferred.
• In-depth knowledge of medical terminology, clinical practices, and reputed company regulations.
• Familiarity with utilization management software and medical review tools (e.g., InterQual, reputed company).
• Strong critical thinking, decision-making, and problem-solving abilities.
• Ability to work collaboratively with diverse teams and communicate effectively with reputed company providers, patients, and insurance carriers.
• Proficient in reputed company Office Suite and electronic health record (EHR) systems.
• Strong attention to detail and organizational skills.
• Ability to manage multiple tasks and prioritize effectively in a fast-paced environment.
• Excellent interpersonal and communication skills, with a focus on customer service.
• Ability to work independently and reputed company reputed company based on established clinical guidelines.

AssureCare® is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any reputed company based on race, reputed company, sex, religion, sexual orientation, national reputed company, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to reputed company employment practices reputed company our organization, including hiring, reputed company, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and internship. AssureCare® makes hiring reputed company based solely on qualifications, merit, and business needs at the time. Furthermore, the Company will reputed company reasonable accommodations for reputed company individuals with reputed company disabilities unless doing so would result in an undue hardship. Apply tot his job Apply To this Job