Registered Nurse Utilization Management

4 weeks ago

Rancho Cordova, United States JobRialto Full time
Job Description

Minimum Qualifications:

Registered Nurse (Current and active California RN license in good standing) required.

BSN/BS/BA and/or Masters Degree in Healthcare related field required.

Demonstrated track record in managed care (5+ years experience preferred).

Strong supervisory and management skills.

Excellent verbal and written communication and computer skills.

Considerable interpersonal skills

Clinical claims review experience is highly desired.

Knowledge of relevant State and Federal laws, statutes and regulations preferred.

Duties:

Review medical records to ensure appropriateness, quality, and cost-effectiveness of healthcare services.

Evaluate the necessity and efficiency of medical treatments, procedures, and hospital admissions.

Communicate with healthcare providers to gather necessary information for decision-making.

Utilize clinical guidelines and evidence-based practices to assess medical necessity.

Collaborate with interdisciplinary teams to develop and implement care plans.

Monitor patient progress and outcomes to ensure continuity and quality of care.

Identify opportunities for improvement in healthcare delivery and utilization.

Provide education and support to patients, families, and caregivers regarding treatment options and resources.

Document all review activities and decisions according to regulatory requirements.

Participate in utilization review committee meetings to discuss cases and trends.

Stay updated on healthcare regulations, policies, and reimbursement guidelines.

Education: Masters Degree

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