Utilization Management RN at The Judge Group Inc. in Los Angeles, California

Job Description:

Location: REMOTE

Salary: $36.00 USD Hourly - $39.00 USD Hourly

Description: We are seeking a Utilization Management RN for a fully remote contract!


Job title: Retrospective/UR Nurse


Hours: Mon- Fri 8am-5pm


Work type: Contract


Location: Fully remote


Job Description:


Responsible for retrospective authorizations of inpatient and outpatient services performed. This role will conduct medical necessity reviews utilizing established medical criteria to aid in reimbursement of services performed. A minimal portion of this role may include telephonic reviews of inpatient hospital admissions, depending on state requirement, requiring extraction of clinical information from the patient record necessary to justify care rendered in the Inpatient and Outpatient setting to meet medical necessity for reimbursement.



This job will have the following responsibilities:

• Provides retrospective clinical review according to state and medical necessity criteria using InterQual guidelines.


• Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.


• Performs follow-up on initial denials received from payors on retrospective clinical reviews by first level of appeal submission.


• Ensure Diagnosis and Procedure codes align with services performed and communicate discrepancies to appropriate contacts per workflow process.


• Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures.


• Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner.


• Knowledge, Skills and Abilities:


• Knowledge of UM principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management desired.


• Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines.
  
  

REQUIRED CERTIFICATIONS/LICENSURE:


• Active, unrestricted State Registered Nursing license or state Licensed Vocational Nursing license in good standing required.


o Must hold and maintain this certification(s) as a professional in the state of residency.




Qualifications & Requirements:

• High School Diploma or equivalent required.


• Completion of an accredited (RN) -OR- an accredited (LVN) program required.


• Bachelor's degree in nursing or health related field preferred.


• Minimum of 3 years clinical practice experience required.


• 2 years utilization management and/or case management required.

If this interests you/you qualify apply as soon as possible! Thank you!


Elizabeth Turner


Healthcare Recruiter


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Contact: eturner@judge.com


This job and many more are available through The Judge Group. Find us on the web at www.judge.com Apply Now