Seeking a UR RN Case Manager with a minimum of three to five years of utilization review experience working in a health plan setting. Knowledge of worker?s compensation is highly desired.
To qualify for this position you must have an Active RN License in the State of California, current or previous experience reviewing complex medical conditions and chronic needs of members, facilitating transitions from one level of care to another through discharge planning. Understanding of Utilization Review techniques including all aspects of the medical review function, including pre-authorizations, concurrent review, and discharge planning. Knowledge of medical claims review and medical documentation. Advanced analytical skills with the ability to interpret and synthesize complex data sets. Negotiable skills, decision-making skills, good problem-solving skills, and the ability to effectively navigate ambiguous situations with limited direction.
The UR Case Manager will be responsible for optimizing member benefits to promote effective use of resources. Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house. Discuss cases with attending physician and other health care professionals, and prepare and refer concerns to Plan Administrative Directors.
Work schedule is Monday - Friday, 7:30am-3:30pm (35 hours per week). Qualified candidates please submit your resume in response to this ad and contact Monique Herrera-Forniss for immediate consideration. We are an equal employment opportunity employer and will consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, age (40 and over), gender identity, national origin, protected veteran status, disability or any other protected classification under federal and state law.