Utilization Management Nurse

4 weeks ago


Philadelphia, United States Insight Global Full time

Location: Philadelphia PA 19103

Duration: 6 month contract to hire

Schedule: Fully Onsite Mon-Fri, 8AM-5PM or 9AM-6PM

Hourly Pay: $40-45/hr

Interview Process: 2 rounds

Must Haves

  • Active NJ or PA RN license
  • 2+ years of experience working in Utilization Review or Utilization Management with commercial payers or Medicare/Medicaid
  • Experience/knowledge of NCQA, CMS and InterQual

Plusses

  • BSN

Day to Day

A Healthcare Insurance company local to Philadelphia PA is looking to hire a Utilization Management Nurse (RN) to their delegation oversight & assessment team. This team is currently working with all case files for commercial and government payer patients. Nurses can expect to perform in depth audits of vendors such as Magellan, Cigna, Epicor, and more payers. Through audit performance, this team ensures that payers and providers adhere to all state and federal regulatory requirements while also ensuring that files/claims are not denied throughout the payment process. This team sits on the front end of claim submission to government and commercial payers. Nurses will begin on the commercial team as they learn the government payer side. Government payer team manages 10 - 25 case files per month. Commercial payer team manages 4 - 5 case files per month. Schedule is Monday through Friday, 8 AM - 5 PM or 9 AM - 6 PM



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