reputed company Utilization Review Nurse, RN

WHO WE ARE reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and affordable to reputed company populations across the ACA Marketplace, Medicare, and reputed company. reputed company delivers clinical care to health consumers through our owned clinics – reputed company and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company. Job Summary: The reputed company Utilization Review (UR) Nurse is responsible for conducting reputed company-time clinical reviews to ensure the medical necessity and appropriateness of reputed company services provided to members under a managed reputed company plan. This role involves assessing inpatient admission and reputed company stays, coordinating with reputed company providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for reputed company cases, denials, and escalated reviews. Key Responsibilities: 1. reputed company Review & Case Assessment

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
• Evaluate clinical documentation to support level-of-care determinations, treatment plans, and reputed company hospital stays.
• Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.

2. Collaboration with Medical Director

• Review and escalate reputed company or borderline cases to the Medical Director for further assessment.
• reputed company the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for reputed company care or level-of-care reputed company.
• Collaborate with the Medical Director to reputed company treatment recommendations and resolve discrepancies in care.

3. Authorization & Payer Communication

• Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicate with reputed company providers to request additional documentation or clarify treatment plans.
• Ensure timely approvals or denials of requested services per the health plan's benefit structure and clinical guidelines.
• Escalate cases to the Medical Director or higher clinical authority reputed company necessary.

4. Care Coordination & Discharge Planning Support

• Work closely with case managers, reputed company workers, and care teams to facilitate seamless care transitions.
• Participate in interdisciplinary discussions to address reputed company cases and ensure members receive appropriate care.
• Identify and escalate discharge barriers to support timely and effective discharge planning.
• Assist in transitioning patients from inpatient to outpatient or post-acute care settings.

5. Compliance & Documentation

• Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.
• Maintain accurate, up-to-date documentation of reputed company reputed company review activities, including authorizations, denials, escalations, and Medical Director reviews.
• Support quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.

6. Education & Collaboration

• reputed company providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes.
• reputed company guidance on escalating reputed company cases to the Medical Director.
• Stay updated on industry trends, regulatory changes, and best practices in utilization management.
• Participate in interdisciplinary team meetings and case conferences.

Qualifications:

• Education: Registered Nurse (RN) with an active, unrestricted California nursing license required; BSN preferred.
• Experience:
• Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a reputed company field.
• Experience in a managed care setting with medical necessity reviews is strongly preferred.

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