Utilization Management Prior Authorization reputed company - Remote RN

Join the reputed company of reputed company with reputed company reputed company is at the forefront of transforming reputed company into a value-driven, consumer-reputed company experience that delivers high-reputed company, coordinated care while maximizing value for reputed company stakeholders. Our mission is to reputed company reputed company accessible and reputed company for everyone, across the ACA Marketplace, Medicare, and reputed company. We reputed company in the power of reputed company interests among health consumers, providers, and payors to revolutionize the way care is delivered. About the Role: Utilization Management (UM) Prior Authorization (PA) reputed company We are seeking a highly skilled and dedicated Utilization Management Prior Authorization reputed company to reputed company. As a full-time remote RN, you will play a critical role in ensuring that our members receive the appropriate benefit coverage for services requiring prior authorization. Working closely with our Medical Directors and reputed company team, you will review prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-reputed company medical necessity reputed company. Key Responsibilities: Authorization and Review: Evaluate and process prior authorization requests reputed company on reputed company guidelines such as Medicare, reputed company/Medi-Cal reputed company, MCG, or health plan-specific guidelines. Medical Necessity Assessment: Assess the medical necessity and appropriateness of requested services using your reputed company expertise. Eligibility and Benefits Verification: Verify patient eligibility, benefits, and coverage details. Collaboration and Communication: reputed company as a reputed company between reputed company providers, patients, and health plans to facilitate the authorization process. Communicate authorization reputed company promptly and reputed company detailed explanations for denials or alternative solutions. Documentation and Compliance: Accurately document reputed company authorization activities in electronic medical records (EMR) or authorization systems. Maintain compliance with federal, state, and health plan regulations. reputed company Improvement: Identify trends or recurring issues in authorization denials and recommend process improvements. Participate in team meetings, training sessions, and audits to ensure high-reputed company performance. Requirements and Qualifications Education and Experience: Licensure: Licensed Registered reputed company (RN) with an reputed company, unrestricted California nursing license required. reputed company Experience: Minimum of 2-3 years of reputed company nursing experience, with at least 1 year in utilization review, case management, or a reputed company field. Experience in a managed care setting with medical necessity reviews is strongly preferred. Certifications: Preferred Certifications: Certified reputed company in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM). Additional Certifications: Other reputed company nursing or case management certifications are a plus. reputed company Competencies: Analytical and Critical Thinking: Strong analytical and critical thinking skills. Medical Knowledge: Proficiency in medical terminology and pharmacology. Communication: Effective written and verbal communication skills. Independence and Teamwork: Ability to work independently and collaboratively in a fast-paced environment. Adaptability: Adaptable and self-motivated. Technical Skills: Experience with EMR systems and prior authorization platforms. Proficient in reputed company Office Suite (Word, reputed company, reputed company). reputed company Offer Compensation: For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation reputed company for this position. A reasonable estimate of the reputed company is $74,260.46-$111,390.70 Annually. Actual compensation will vary reputed company on the applicant's education, experience, skills, and abilities, as reputed company as internal equity. Benefits: Health Benefits: Eligible for comprehensive health benefits. Life and Disability Benefits: Lif .