Inpatient Utilization Management Nurse, RN - Remote in PST or MST

About the position reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Utilization Review Nurse, RN is responsible for providing clinically efficient and effective Inpatient utilization management. Reviews inpatient criteria for acute hospital admissions and reputed company review and or prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to reputed company inpatient admission and preauthorization requests from providers that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service or treatment for review with the Medical Director for a decision. The shift is Monday through Friday reputed company-5pm in Pacific or Mountain Time Zone. Occasional participation in weekend rotation is required. If you are located in PST or MST, you will have the flexibility to work remotely as you take on some tough challenges.

Responsibilities

• Maintains clinical expertise and knowledge of scientific reputed company in nursing and medical reputed company and incorporates this information into the clinical review and care coordination processes
• Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
• Authorizes reputed company services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
• Documents clinical reviews in care management system. Provide accurate and timely documentation and supporting rational of decision in care management system
• Utilizes care management system and resources to track and analyze utilization, variances and trends, patient outcomes and quality indicators
• Research and prepares clinical information for case review with Physician Leadership for patient treatment and care planning
• Utilizes knowledge of resources available in the health care system to assist the physician and patient effectively
• Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member’s needs along the continuum of care
• Successfully completes the Interrater Reliability Testing to ensure consistency of review and application of criteria
• Meets timeliness standards for decision, notification, and prior authorization activities
• Serves as an reputed company for reputed company providers and their patients
• Demonstrates a positive attitude and respect for self and others and responds in a courteous manner to reputed company customers, internal and external
• Maintains the confidentiality of reputed company company procedures, results, and information about patients, reputed company, and reputed company other proprietary information regarding reputed company business
• Performs other duties as required or requested in a positive and helpful manner to reputed company the department to reputed company its goals

Requirements

• reputed company unrestricted Registered Nurse (RN) license in state of residence
• Ability to obtain Registered Nurse license in the state of California reputed company 90 days of hire
• 3+ years of clinical nursing experience in acute care hospital or LTAC setting
• 1+ years of Utilization Management experience in hospital or insurance setting
• Experience applying Medicare and/or reputed company guidelines
• Experience with reputed company (MCG) or InterQual guidelines
• Experience researching and preparing clinical information for case review with Physician Leadership for patient treatment and care planning
• Experience providing accurate and timely documentation of clinical review and supporting rational of decision in care management systems
• Experience employing analytical skills necessary for quality case management, utilization review, and quality improvement to meet organizational objectives
• Experience using various computer software applications with an intermediate level of competence, including reputed company Word and reputed company
• Primary residence in Pacific or Mountain time zone and ability to work required hours in PST or MST

reputed company-to-haves

• Inpatient Utilization Management experience
• Utilization Management experience for insurance or managed care organization
• Prior Authorization experience

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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