Imperial Health Plan of California, Inc.
Utilization Management Review Denials Nurse, RN
Imperial Health Plan of California, Inc., Pasadena, California, United States, 91122
3 days ago Be among the first 25 applicants
Imperial Health Plan of California, Inc. provided pay range This range is provided by Imperial Health Plan of California, Inc.. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base pay range $40.00/hr - $42.00/hr
Direct message the job poster from Imperial Health Plan of California, Inc.
About the Role The UM Denials Specialist, RN will be responsible for managing the denials process and ensuring compliance with medical necessity criteria.
Responsibilities
Completes the denials process for requested services and IP hospital stays that fail to meet medical necessity consistent with MCG or CMS criteria.
Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Imperial Healthcare guidelines.
Refer cases not meeting criteria for medical necessity to Medical Director during inpatient rounds.
Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance and Risk Management, as appropriate.
Develop medical summaries of denied cases for review by the Medical Directors.
Identify and implement strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
Identify system delays in service to improve the provision of efficient and timely patient care.
Identify process issues related to the UM concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
Assure quality care by adhering to standards set by the physicians.
Provide care education to patients in person or over the phone.
Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA).
Qualifications
Must be a Registered Professional Nurse with current licensure.
2 to 3 years clinical experience required.
2 to 3 years UM experience in a health care setting preferred.
1-2 years background/experience with audits preferred.
Knowledge of OSHA, FDA, and HIPAA compliance.
RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license.
Required Skills
Strong understanding of the preauthorization process.
Ability to liaise with providers/staff.
Regulatory awareness.
Seniority level
Associate
Employment type
Full-time
Job function
Administrative and Health Care Provider
Hospitals and Health Care
Referrals increase your chances of interviewing at Imperial Health Plan of California, Inc. by 2x
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Imperial Health Plan of California, Inc. provided pay range This range is provided by Imperial Health Plan of California, Inc.. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base pay range $40.00/hr - $42.00/hr
Direct message the job poster from Imperial Health Plan of California, Inc.
About the Role The UM Denials Specialist, RN will be responsible for managing the denials process and ensuring compliance with medical necessity criteria.
Responsibilities
Completes the denials process for requested services and IP hospital stays that fail to meet medical necessity consistent with MCG or CMS criteria.
Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Imperial Healthcare guidelines.
Refer cases not meeting criteria for medical necessity to Medical Director during inpatient rounds.
Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance and Risk Management, as appropriate.
Develop medical summaries of denied cases for review by the Medical Directors.
Identify and implement strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
Identify system delays in service to improve the provision of efficient and timely patient care.
Identify process issues related to the UM concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
Assure quality care by adhering to standards set by the physicians.
Provide care education to patients in person or over the phone.
Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA).
Qualifications
Must be a Registered Professional Nurse with current licensure.
2 to 3 years clinical experience required.
2 to 3 years UM experience in a health care setting preferred.
1-2 years background/experience with audits preferred.
Knowledge of OSHA, FDA, and HIPAA compliance.
RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license.
Required Skills
Strong understanding of the preauthorization process.
Ability to liaise with providers/staff.
Regulatory awareness.
Seniority level
Associate
Employment type
Full-time
Job function
Administrative and Health Care Provider
Hospitals and Health Care
Referrals increase your chances of interviewing at Imperial Health Plan of California, Inc. by 2x
#J-18808-Ljbffr