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.
