RN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr

cvhp; Covina (CA); On-site; USD 7,164,000 - 11,159,000; Full time

Job summary

Emanate Health in Covina, CA, seeks a Utilization Review Nurse to evaluate medical records and determine medical necessity using policies and guidelines for urgent and standard reviews. You will document decisions and support claims reviews, applying clinical judgment throughout the process.

California RN license required; minimum three years' utilization management experience; strong customer service skills. Deliver world-class health care one patient at a time.

Qualifications

• Three years of utilization management experience.
• Excellent customer service skills.

Responsibilities

• Evaluate medical records to determine medical necessity using policies and guidelines for urgent and standard reviews.
• Document decisions using indicated protocol sets or clinical guidelines and support medical claims and utilization practices.
• Complete medical necessity and level of care reviews and refer to Medical Directors when needed.

Skills

Utilization management

Job description

Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals.

On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country.

Job Summary

The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Job Requirements

Minimum Education Requirement

Minimum Experience Requirement

Minimum of three years of utilization managementexperience. Experience in quality- related job preferred. Computer proficiency is required. Excellent customer service skills required.

Minimum License Requirement

California RN license.

Delivering world-class health care one patient at a time.

Pay Range:

$52.03 - $80.64