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Med Mgmt Clinician Sr

The Judge Group

Los Angeles (CA)

Remote

Full time

Yesterday

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Job summary

A leading healthcare organization is seeking a Remote Medical Management Clinician in Woodland Hills, CA. The role focuses on utilization review and requires a valid nursing license. Candidates will handle moderately complex cases and collaborate with healthcare providers while working from home.

Qualifications

Requires a minimum of 4 years of clinical experience and/or utilization review experience.
Current active, valid and unrestricted LPN/LVN license or RN license required.

Responsibilities

Responsible for ensuring appropriate administration of plan benefits.
Conducts and may approve precertification and medical necessity reviews.

Skills

Clinical Experience

Utilization Review

Education

H.S. diploma or equivalent

LPN/LVN license or RN license

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Location: Los Angeles, CA

Salary: $38.00 USD Hourly - $41.00 USD Hourly

Description

Judge Healthcare is currently seeking a Remote Medical Management Clinician for a fantastic client of our in Woodland Hills, CA!

Below you can find a basic overview of the opportunity. Qualified candidates are encouraged to apply!

Job Title: Utilization Review Specialist

Location: Woodland Hills, CA

Job Description

Responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. May collaborate with healthcare providers. Focuses on moderately complex case types that do not require the training or skill of a registered nurse.

Primary Duties

Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
Work may be facilitated, in part, by algorithmic or automated processes.
Handles moderately complex benefit plans and/or contracts.
Works on reviews that may require guidance by more senior colleagues and/or management.
May serve as a resource to less experienced staff.
Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract.
May process a medical necessity denial determination made by a Medical Director.
May work directly with healthcare providers to obtain and understand clinical information.
Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
May educate members about plan benefits and physicians.
Does not issue medical necessity non-certifications.

Qualifications

Requires H.S. diploma or equivalent.
Requires a minimum of 4 years of clinical experience and/or utilization review experience.
Current active, valid and unrestricted LPN/LVN license or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Multi-state licensure is required if this individual is providing services in multiple states.
This will be a Monday-Friday 7am-3:30 pm but you will be able to work from home!

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Contact: jmaybrier@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

Seniority level

Seniority level
Mid-Senior level

Employment type

Employment type
Contract

Job function

Job function
Health Care Provider
Industries
Hospitals and Health Care and Medical Practices

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