RN or LVN Utilization Review

Employer
Medical Professionals
Location
Redwood City, CA, US
Salary
Competitve
Posted
Aug 28, 2017
Closes
Sep 28, 2017
Ref
a70d1737
Specialty
LPN / LVN
Contract Type
Permanent
Job Description

We are seeking a RN or LVN to join the Utilization Team Department!

  • Review medical records, benefit, and other guidelines to determine benefit coverage, , scope availability, and level of care considerations.
  • Work closely with Primary Care and Specialist physicians, Medical Director, ancillary providers and case management to coordinate member care.
  • Update and processes member records.
  • Physician and ancillary Providers and Health Plans with issues that require medical interpretation, research or clarification.
  • Clarifies information and answers prior authorization questions from medical offices and providers

  • Performs audit of prior authorization database to monitor timelines set by NCQA.

  • Prepares frequent emergency room usage information for UM management.

Requirements:

  • RN or LVN license in CA
  • BS or BA
  • 3+ years of relevant experience

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