Job Description:

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
• Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
• Input and manage essential clinical details within various medical management platforms.
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
• Apply clinical reasoning to determine the suitable evidence-based guidelines.
• Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.

Requirements:

• Proficient in both written and spoken communication.
• Capable of maintaining professional communication with physicians and clients.
• Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting.
• Possesses a keen organizational sense and pays close attention to details.
• Adept at resolving intricate and multifaceted problems.
• Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
• Background in medical or clinical practice through education, training, or professional engagement.
• Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).
• 2 yrs minimum clinical nursing experience is required.
• One year of previous experience in Utilization Management is required.

Benefits:

• medical, dental, and vision coverage for you and your family
• voluntary life insurance options for you, your spouse, and your children
• other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• basic life insurance
• short-term disability
• long-term disability coverage at no cost
• generous paid time off policy
• 401k plan with a company match
• Apple equipment and a media stipend are provided for remote workspace