Current jobs related to Utilization Review Nurse - Corona - KPC Global MSO
-
Nurse Utilization Review Specialist
2 weeks ago
Corona, New York, United States VNS Health Full timeJob Title: Registered Nurse - Utilization ReviewVNS Health is seeking a skilled Registered Nurse to join our team as a Utilization Review Specialist. In this role, you will play a critical part in ensuring the highest quality of care for our patients.Job Summary:The Registered Nurse - Utilization Review will be responsible for conducting clinical...
-
Nurse Utilization Review Specialist
2 weeks ago
Corona, New York, United States VNS Health Full timeJob Title: Registered Nurse - Utilization ReviewVNS Health is seeking a skilled Registered Nurse to join our team as a Utilization Review Specialist. In this role, you will play a critical part in ensuring the highest quality of care for our patients.Job Summary:The Utilization Review Specialist will be responsible for conducting clinical assessments,...
-
Utilization Review LVN
5 months ago
Corona, United States KPC GLOBAL MEDICAL CENTERS INC Full timeJob DescriptionJob DescriptionCoordinates and reviews all medical records, as assigned to caseloadActively participates in Case Management and Treatment Team meetingsServes as on-going educator to all departmentsResponsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering...
-
Utilization Review Nurse
4 months ago
Corona, United States KPC GLOBAL MEDICAL CENTERS INC Full timeJob DescriptionJob DescriptionVictor Valley Global Medical CenterVictorville, CACoordinates and reviews all medical records, as assigned to caseloadActively participates in Case Management and Treatment Team meetingsServes as on-going educator to all departmentsResponsible for reviewing patient charts in order to assess whether the criteria for admission and...
-
QA/QC Utility Inspector
4 weeks ago
Corona, United States Summit Line Construction Full timeAbout Us Summit Line Construction, a subsidiary of Quanta Services, Inc. (NYSE: PWR), is one of North America's premier utility construction companies. Headquartered in Heber City, Utah, we offer powerline and substation construction and maintenance services in a variety of utility markets. Like many Quanta operating companies, Summit Line continues to...
-
Clinical Appeals Nurse
18 hours ago
Corona, California, United States KPC GLOBAL MEDICAL CENTERS INC. Full timeJob SummaryWe are seeking a highly skilled Clinical Appeals Nurse to join our team at KPC Global Medical Centers Inc. The successful candidate will be responsible for investigating and processing medical necessity appeals from members and providers to payers.Key ResponsibilitiesConduct thorough research on standards of practice, regulations, and policy...
-
Clinical Appeals Nurse
4 months ago
Corona, United States KPC GLOBAL MEDICAL CENTERS INC. Full timeJob DescriptionJob DescriptionLVN RANGE $38.91-$55.62RN RANGE $50-$85Job Description: Conduct and investigate member and provider medical necessity appealsReview prospective, inpatient, and retrospective medical records of denied services for medical necessityEnsures appeals and grievances are resolved in a timely mannerPrepare clinical reviews and provides...
-
Medical Care Nurse Specialist
5 days ago
Corona, New York, United States VNS Health Full timeJob Title: Medical Care NurseVNS Health is seeking a skilled Registered Nurse to join our team as a Clinic Utilization Review professional in West New York, New Jersey.Job Summary:We are looking for a highly motivated and detail-oriented Registered Nurse to resolve grievances, appeals, and external reviews for our VNS Health Plans product lines. The ideal...
-
Nurse Educator
2 weeks ago
Corona, New York, United States HealthEcareers - Client Full timeAbout the RoleWe are seeking a highly skilled Nurse Educator to join our team at HealthEcareers - Client. As a Nurse Educator, you will play a critical role in shaping the future of healthcare through education and training.Key ResponsibilitiesDevelop and deliver high-quality clinical education programs to foster high-quality care through evidence-based...
-
Medical Care Specialist
4 days ago
Corona, New York, United States VNS Health Full timeJob Title: Medical Care SpecialistVNS Health is seeking a skilled Medical Care Specialist to join our team in West New York, New Jersey.About the Role:This is a nursing job that requires a Registered Nurse (RN) with experience in clinic utilization review. The successful candidate will be responsible for resolving grievances, appeals, and external reviews...
-
Staff Nurse Educator
4 days ago
Corona, New York, United States VNS Health Full timeJob Title: RN Educator (Health Plans)VNS Health is seeking a Registered Nurse (RN) Educator to join our team in West New York, New Jersey. As an RN Educator, you will play a critical role in shaping the future of healthcare through education and training.Job Summary:The RN Educator will be responsible for managing and delivering program-specific clinical...
-
Registered Nurse
4 weeks ago
Corona, United States Oak Street Health Full time $89,600 - $107,600Company: Oak Street HealthIf your skills, experience, and qualifications match those in this job overview, do not delay your application.Title: Center NurseLocation: 97-01 Northern Boulevard Flushing, New York 11368Salary: $89,600 to $107,600**Does not include additional forms of compensation including bonuses, overtime, etc.The minimum base wage for this...
-
CDIS - Clinical Doc Improvement Specialist
4 months ago
Corona, United States KPC GLOBAL MEDICAL CENTERS INC. Full timeJob DescriptionJob DescriptionSUMMARYThe Clinical Documentation Specialist (CDS)/Coder III is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services...
-
Corona, United States KPC GLOBAL MEDICAL CENTERS INC. Full timeJob DescriptionJob DescriptionLocation: Central Business OfficeJob Title: Clinical Documentation Specialist (CDS)/Coder IIIDepartment: Health Information ManagementReports to: Director OF Coding and CDI operationsCompletion Date:SUMMARYThe Clinical Documentation Specialist (CDS)/Coder III is responsible conducting clinically based concurrent and...
-
Registered Nurse
2 weeks ago
Corona, United States UHS Full timeResponsibilities Registered Nurse (RN) - ICUFull-time, Night Shift position located at Corona Regional Medical Center (CRMC) in Corona, CAThis position qualifies for a hiring bonus!The tradition of caring that culminated in the establishment of Corona Regional Medical Center® began in 1965, with the founding of Corona Community Hospital. Since that time the...
-
Registered Nurse
1 month ago
Corona, United States UHS Full timeResponsibilities Registered Nurse (RN) - ICU Full-time, Night Shift position located at Corona Regional Medical Center (CRMC) in Corona, CA This position qualifies for a hiring bonus! The tradition of caring that culminated in the establishment of Corona Regional Medical Center® began in 1965, with the founding of Corona Community Hospital. Since that time...
-
Nurse Specialist
2 weeks ago
Corona, California, United States BioLife Plasma Services Full timeAbout the RoleWe are seeking a skilled and compassionate Nurse Specialist to join our team at BioLife Plasma Services. As a key member of our healthcare team, you will play a vital role in ensuring the health and safety of our donors.Your primary responsibilities will include determining donor eligibility, managing donor adverse events, reviewing laboratory...
-
Registered Nurse
3 days ago
Corona, United States Quality Talent Group Full timeAbout the job Registered Nurse (RN) Unit Manager St. Patrick's Home Rehabilitation and Health Care is actively seeking a Registered Nurse (RN) Unit Manager for our Skilled Nursing Facility in the Bronx, NY. Duties: Handle all supervisory duties for assigned unit Help establish and implement employment policies and procedures Mentor less experienced nurses,...
-
Registered Nurse
3 days ago
Corona, United States UHS Full timeResponsibilities Come Join the Team! Registered Nurse (RN) - Stepdown Part-time, Night Shift position located at Corona Regional Medical Center in Corona, CA This position also qualifies for a hiring bonus! The tradition of caring that culminated in the establishment of Corona Regional Medical Center began in 1965, with the founding of Corona Community...
-
Nurse Specialist
7 days ago
Corona, California, United States BioLife Plasma Services Full timeAbout the RoleAs a Medical Support Specialist at BioLife Plasma Services, you will play a vital role in ensuring the quality and safety of plasma donations. Your primary responsibility will be to determine donor eligibility, manage donor adverse events, and review laboratory test results. You will also be responsible for notifying donors of unsuitable test...
Utilization Review Nurse
3 months ago
Victor Valley Global Medical Center
Victorville, CA
- Coordinates and reviews all medical records, as assigned to caseload
- Actively participates in Case Management and Treatment Team meetings
- Serves as on-going educator to all departments
- Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
- Able to work independently and use sound judgment.
- Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
- Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
- Responsible for providing timely and accurate referral determination
- Identification of referrals to the medical director for review
- Appropriate letter language and coding (denials, deferrals, modifications)
- Appropriate selection of the preferred and contracted providers
- Proper identification of eligibility and health plan benefits
- Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
- Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
- Meets or exceeds production and quality metrics.
- Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
- Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
- Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
- Performs other duties as assigned.
EDUCATION & EXPERIENCE REQUIREMENTS:
- CA LVN license required. CA RN license preferred.
- Bachelor’s or Master’s degree in Social Work, behavioral or mental health, nursing or other related health field preferred
- 3 to 5 years of acute care experience preferred.
- Two (2) years managed care experience in UM/CM Department, preferred
- Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
- ICD-9 and CPT coding experience a plus
- Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
- Experience in EZ-CAP preferred
- Medical Terminology preferred
The posted pay scale represents the range the Company reasonably expects to pay candidates for this position. The actual wage for this position may depend on factors such as experience and education, specific skills and abilities, alignment with similar internal candidates, marketplace factors, an applicable collective bargaining agreement, and Company business practices.
