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

Emanate Health; Covina (CA); On-site; USD 50,000 - 85,000; Full time

Job summary

Join a leading health care system recognized for excellence, where your role as a Utilization Review Nurse will be pivotal in evaluating medical records and ensuring the delivery of quality care. In this position, you will apply your clinical acumen to assess medical necessity and support medical claims, all while being part of a dedicated team that values community impact and individual growth. With a strong emphasis on collaboration and excellence, this is an opportunity to contribute to a top-ranked health care organization while enhancing your professional skills in a supportive environment.

Qualifications

• Minimum of three years of utilization management experience.
• California RN license is required.

Responsibilities

• Evaluate medical records to determine medical necessity.
• Document decisions using clinical guidelines and protocols.

Skills

Utilization Management

Clinical Judgment

Customer Service Skills

Computer Proficiency

Education

California RN License

Job description

Current Emanate Health Employees - Please log into your Workday account to apply

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 management experience. 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