RN or LVN Utilization Review
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.
- RN or LVN license in CA
- BS or BA
- 3+ years of relevant experience