Location: Los Angeles, CA
Description: Our client is currently seeking a Nurse Medical Mgmt I
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
Primary duties may include, but are not limited to: Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards
Requirements:
• Current valid and unrestricted License as a Registered Nurse through the appropriate issuing state agencies.
• Minimum of 2 years of managed care experience and acute care experience
• Experience performing utilization review of inpatient admissions, outpatient surgeries, and ancillary services.
• Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
• Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.
• Strong interactive, oral and written communication skills.
• Excellent critical thinking, deductive reasoning and decision making skills.
• Ability to work as a team member and participate in the assessment and evaluation process of potential and existing participants.
• Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.
– Knowledge of MCG guidelines required
Client Note:
Full time position. Monday thru Friday, with 8-5pm
Location: Open to anywhere, with a focus on CA, AZ, NV, or VA. If candidate has a compact license, that’s even better. Position will be 100% remote
Location: Open to anywhere, with a focus on CA, AZ, NV, or VA. If candidate has a compact license, that’s even better. Position will be 100% remote
Please send qualified resumes to Dave Friedman at Dfriedmna@judge.com
Contact: dfriedman@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com