Nurse RN 3

TALENT Software Services; California (MO); Remote; USD 74,000 - 112,000; Full time

Job summary

A leading IT Services and Consulting company is seeking a UM Prior Authorization Nurse, RN to work from home. This role involves performing concurrent reviews for inpatient admissions and ensuring compliance with clinical criteria. The candidate should possess strong acute care experience and excellent communication skills, contributing to expedited member care and quality assurance.

Qualifications

• 3-5 years of acute care experience is required.
• Strong computer skills related to Windows-based programs.
• Good communication skills are essential.

Responsibilities

• Perform concurrent reviews for inpatient admissions.
• Communicate determinations to providers and/or members.
• Develop determination recommendations and present cases to MD.

Skills

Acute Care Experience

Computer Skills

Communication Skills

Job description

Job Title: UM Prior Authorization Nurse, RN (Work from home)

Location: Los Angeles, CA

Salary Range: $74,260.46 - $111,390.70

Employment Type: Full-time

Job Responsibilities:

1. Performs concurrent reviews for inpatient admissions using evidence-based guidelines, policies, and nationally recognized clinical criteria across the line of business. Ensures diagnosis matches ICD-10 codes.
2. Triages and prioritizes cases to meet required regulatory turn-around times. Expedites access to appropriate care for members with urgent needs through an expedited review process.
3. Develops determination recommendations. Presents cases to the Medical Director (MD) for treatment denials as required.
4. Communicates determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
5. Prepares and reviews member-centered documentation and correspondence reflecting determinations, ensuring compliance with regulatory and accreditation standards.
6. Identifies potential quality of care issues, service or treatment delays, intervenes as clinically appropriate.
7. Identifies potential Third Party Liability and Coordination of Benefit cases, notifying appropriate internal departments.
8. Provides referrals to Case Management and Disease Management programs.

Required Skills (Top 3 Non-negotiables):

1. Minimum 3-5 years of Acute Care Experience
2. Strong computer skills related to Windows-based programs and applications
3. Good communication skills

Preferred Skills:

• Varied clinical background
• Previous experience in prior authorization or utilization management

Additional Information:

• Seniority level: Mid-Senior level
• Industries: IT Services and IT Consulting

This job posting is active and not expired.