Remote RN: Medical Management & Utilization Specialist

SCAN; Long Beach (CA); Remote; USD 62,000 - 69,000; Full time

Benefits offered by this job

Remote work mode

401(k) with employer match

Opportunity to make a difference

Job summary

SCAN, a nonprofit health organization, seeks an experienced Medical Management Specialist-RN in California. You will promote quality and cost-effective care, conduct pre-service reviews, and coordinate complex medical needs under clinical supervision.

Remote work mode, 3–6 month contract, with strong emphasis on regulatory compliance. Qualifications include an active CA RN license, nursing degree, and 3+ years in medical-surgical nursing and utilization management in managed care.

Qualifications

• Nursing degree required.
• Active California RN license required.
• CPUM or CPUR certification preferred or willing to attain with 2 years.
• 3+ years of medical-surgical nursing experience.
• 3+ years of Utilization Management/Prior Authorization in a managed care setting.
• Knowledge of California managed care, Medicare/MediCal required.
• Knowledge of federal and state healthcare mandates and regulations.
• Health plan and vendor contracting knowledge.
• Proficient in MS Word, Excel, Outlook, and PowerPoint.
• Strong analytical and problem-solving skills.
• Strong verbal and written communication skills.
• Ability to multitask in a fast-paced environment.
• ICD-9, HCPCS and CPT coding knowledge.

Responsibilities

• Promote and support the quality, medical necessity and cost effectiveness of care.
• Conduct pre-service and concurrent reviews following established guidelines.
• Apply case management principles to coordinate complex medical needs and services.
• Prepare and deliver case presentations and participate in IDT meetings.
• Assist members with urgent and emergent medical needs, including out-of-network care.
• Maintain documentation and data entry adhering to policies.

Skills

Analytical skills

Communication skills

Multitasking

Problem-solving

MS Office

Coding knowledge

Teamwork

Education

Nursing degree

California RN license

CPUM/CPUR certification

Tools

Microsoft Word

Excel

Outlook

PowerPoint

Job description

SCAN, a nonprofit health organization, seeks an experienced Medical Management Specialist-RN in California. You will promote quality and cost-effective care, conduct pre-service reviews, and coordinate complex medical needs under clinical supervision.

Remote work mode, 3–6 month contract, with strong emphasis on regulatory compliance. Qualifications include an active CA RN license, nursing degree, and 3+ years in medical-surgical nursing and utilization management in managed care.