Utilization Review Nurse (100 REMOTE) - Fontana - Amerit Consulting

Description

Our client, a Medical Center facility under the aegis of a California Public Ivy university and one of largest health delivery systems in California, seeks an accomplished Utilization Review Nurse.

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NOTE- THIS IS 100% REMOTE ROLE & ONLY W2 CANDIDATES/NO C2C/1099

*** Candidate must be authorized to work in USA without requiring sponsorship ***

Position: Utilization Review Nurse (Job Id

Location: Los Angeles CA % REMOTE)

Duration: 3 Months + Possible Extension

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Job Description:

We are seeking an experienced Utilization Management Review Nurse with a strong background in outpatient prior authorization within a health plan or managed care environment. The ideal candidate is a California licensed RN who can independently review clinical documentation, apply evidence based medical necessity criteria, and make sound authorization decisions in a high volume setting. This role requires confident communication with physicians, payers, and internal teams, strong critical thinking skills, and a solid understanding of Medicare, Medi Cal, and health plan utilization review requirements.The Utilization Management Review Nurse is responsible for the review and evaluation of clinical information and documentation related to prior authorization requests for medical services. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory, accreditation, and departmental requirements. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for external teams such as customer service and claims. Utilizes advanced practice nursing skills in the assessment, education, and coordination of care for an identified group of patients. Collaborates and consults with the multi-disciplinary team, including but not limited to Physicians, Nursing, Ancillary, Professional, Technical, and other clinical and/or department team members along with patients and families to ensure safe and effective coordination of care. Participates in performance improvement projects/processes and other duties as assigned.

Required Experience:

• Current unrestricted Registered Nurse license in the state of California
• Minimum of 3 years of utilization management or prior authorization experience in an outpatient setting
• Direct experience performing prior authorization reviews for a health plan, managed care organization, IPA, MSO, or healthcare plan administrator
• Experience applying evidence based medical necessity criteria such as InterQual, Milliman, CMS, and health plan specific guidelines
• Demonstrated ability to independently review clinical documentation and determine medical necessity, level of care, approval, denial, or need for physician review
• Experience communicating medical necessity decisions to physicians, clinical staff, payers, and internal departments
• Strong background in abstracting and interpreting medical records to support utilization review decisions
• Working knowledge of Medicare, Medi Cal, and CCS utilization review requirements and regulations
• Experience collaborating with physician reviewers and interdisciplinary clinical teams to resolve authorization requests
• Proven ability to manage a high volume caseload in a fast paced remote or office based environment
• Must have prior authorization experience in an outpatient setting. (Must have health plan or healthcare plan administrator experience. Prior authorization nurse, clinical review nurse)
• Current unrestricted RN licensure in CA
• 3-5 years' experience in utilization management, preferred.
• Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high volume work environment.
• Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills (Required).
• Proficient knowledge in evidence-based medical necessity criteria, health plan medical necessity criteria and CMS criteria. (Required)
• Strong critical thinking and the ability to apply knowledge
• Ability to work effectively and collaboratively with interdisciplinary teams.
• Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX). (Required)
• Ability to effectively communicate to physician/staff the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization.
• Ability to effectively communicate to the payer the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization.
• Skill in setting priorities that accurately reflect the relative importance of job responsibilities.
• Skill in abstracting and interpreting medical information from patient records.
• Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS.
• Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel.
• Ability to develop an individualized case management plan that addresses physical, vocational, psychosocial, financial, and educational needs.

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Bhupesh Khurana

Lead Technical Recruiter

Email –

Company Overview:

Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients businesses forward.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws