Utilization Review Nurse

Remote

2 month contract with probable extension

Job Description

Ensuring appropriate, cost-effective, and high-quality care for New Century Health Plan members

Conducting utilization management (UM) activities in accordance with health plan policies and regulatory guidelines

Identifying and reporting Potential Quality Issues (PQI) and supporting Provider Dispute Resolution (PDR) processes to ensure compliance and foster provider satisfaction

Completing other duties as assigned

We're Seeking a Highly Qualified Candidate With

A BSN or MSN degree, required
Current valid California RN license, required
Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care
Knowledge of Medicare Advantage regulatory guidelines, including CMS regulations
Experience with Potential Quality Issues (PQI) identification and reporting
Familiarity with Provider Dispute Resolution (PDR) processes
Strong clinical assessment and critical thinking skills
Proficiency in electronic health records (EHR) and utilization management software
Excellent written and verbal communication skills

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

E-talentnetwork

New Jobs

Non-Clinical - Nurse Coordinator