Registered Nurse - Utilization Review - Sacramento
RN - Utilization Review
The city of Sacramento is the capital of California, with a population of over 500,000. The broader Sacramento metro area is home to over 2.4 million residents. Sacramento is a major center for healthcare, with world-renowned UC Davis School of Medicine close by, making it an ideal location for talented healthcare professionals. Whether you prefer to work in a hospital, clinic, home care or senior housing setting - Sacramento job opportunities in healthcare are abundant.
Are you looking to ensure that patients receive necessary care without burdening the health care system with unnecessary procedures? Come work behind the scenes to maximize the quality and cost efficiency of health care services!
RN - Utilization Review Summary:
- Review prospective, inpatient, or retrospective medical records of denied services for medical necessity
- Conduct investigations and reviews of member and provider grievances and appeals
- Extrapolate and summarize medical information for medical director, consultants and other external review
- Prepare recommendations to either uphold or deny appeal and forwards to Medical Director for approval
- Serve as a technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives
- Ensure that appeals and grievances are resolved timely to meet regulatory time frames.
- Document and log appeal/grievance information on relevant tracking systems and mainframe systems
- Generate appropriate written correspondence to providers, members, and regulatory entities
RN - Utilization Review Qualifications:
- Current active unrestricted RN license
- Utilization Management experience highly desired
- Requires 2-4 years or more of experience in a managed care healthcare setting
- Medicaid experience preferred.
- Minimum of 5 years of direct-care experience strongly preferred