Senior Utilization Review Nurse - Managed Care Expert

Wollborg Michelson Recruiting; Cameron Park (CA); Presencial; USD 90.000 - 130.000; Jornada completa

Descripción de la vacante

Wollborg Michelson Recruiting is seeking a Senior Utilization Management Nurse in California. The role reviews facility claims for medical necessity, contract compliance, and hospital billing accuracy, with detailed audits of medical records to determine the appropriate level of care.

The ideal candidate holds a California RN license, has 5+ years of experience, and demonstrates strong documentation and independent work capabilities, including effective communication with providers and payors.

Formación

• Licensed RN in California with the ability to perform utilization reviews.
• Minimum five years of relevant professional experience.
• Strong computer navigation and documentation skills.

Responsabilidades

• Perform retrospective utilization reviews and first-level determinations.
• Review claims for medical necessity, coding accuracy, and contract compliance.
• Prepare and present cases to Medical Director for determinations.
• Communicate determinations to providers and members per regs.
• Audit itemized hospital bills for billing logic and accuracy.
• Identify quality-of-care issues and intervene when needed.
• Triage cases to meet turnaround times and maintain efficiency.

Conocimientos

Utilization management

Clinical review

Coding accuracy

Regulatory knowledge

Communication

Educación

California RN license

Herramientas

Computer software

Descripción del empleo

Wollborg Michelson Recruiting is seeking a Senior Utilization Management Nurse in California. The role reviews facility claims for medical necessity, contract compliance, and hospital billing accuracy, with detailed audits of medical records to determine the appropriate level of care.

The ideal candidate holds a California RN license, has 5+ years of experience, and demonstrates strong documentation and independent work capabilities, including effective communication with providers and payors.