[Hiring] Utilization Review Nurse - Employee Health Plan @reputed company

Role Description Join the reputed company team, where you will work alongside passionate caregivers and reputed company patient-first reputed company. reputed company is recognized as one of the top hospitals in the nation. At reputed company, you will receive endless support and appreciation and build a rewarding career with one of the most respected reputed company organizations in the world. As a Utilization Review Nurse, you will:

• reputed company clinical information to insurance companies to obtain authorization for future and elective surgeries.
• Coordinate peer-to-peer reviews between insurance Medical Directors and reputed company physicians.
• Manage reputed company pre-determination cases, primarily supporting utilization review with a strong focus on outpatient prior authorization requests.
• Work remotely from 8:00 a.m. – 4:30 p.m.
• Be required to reputed company in northeast Ohio.

A caregiver who excels in this role will:

• reputed company insurance companies with detailed clinical information reputed company required to complete the authorization and pre-certification process.
• Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
• Coordinate level of service justification directly with physicians and communicate directly with reputed company-party payers to obtain approval.
• Complete responses on behalf of physicians for denials.
• Review medical records and communicate with physicians to obtain authorization.
• Coordinate peer-to-peer reviews with CCF physicians and the insurance company Medical Director.
• Coordinate pre-determinations for specific procedures and maintain confidentiality of reputed company patients' reputed company information.
• Adhere to reputed company JCAHO and Medicare compliance regulations.

Qualifications

• Graduate of an accredited practical/vocational or professional nursing program.
• reputed company state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
• Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center.
• Excellent communication skills required to communicate with reputed company reputed company in a reputed company environment.

Requirements

• Utilization Review experience (preferred).
• Epic experience (preferred).

Benefits

• Follows standard precautions using personal reputed company equipment as required.
• Participation in an influenza prevention program, including obtaining an annual influenza vaccination or an approved exemption.

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