Job Summary
A healthcare and operational efficiency focused consultancy is searching for a person to fill their position for a Remote Managed Care Payer California Licensed Registered Nurse.
Core Responsibilities Include:
- Performing concurrent reviews of inpatient claims
- Performing prior authorization reviews for outpatient services
- Following and maintaining compliance with CMS requirements
Qualifications Include:
- Current unencumbered RN license in California
- 2+ Utilization management experience with a health insurance company (managed care/payer experience required)
- UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side
- 5+ years of acute clinical experience
- Proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria
- The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families