RN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr

Emanate Health Foothill Presbyterian Hospital • Covina, CA

1d • Onsite

About The Position

The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Requirements

• Minimum of three years of utilization management experience
• Computer proficiency is required
• Excellent customer service skills required
• California RN license

Nice To Haves

• Experience in quality-related job preferred

Responsibilities

• Evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews
• Document decisions using indicated protocol sets, or clinical guidelines
• Provide support and review of medical claims and utilization practices
• Complete medical necessity and level of care reviews for requested services using clinical judgment
• Refer to Medical Directors for review depending on case findings

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees