Utilization Review RN

Prime Healthcare • Ontario, CA

6d

About The Position

Overview Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! #LI-KT1 #Appcast Responsibilities Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.

Requirements

• Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.
• Minimum 3 years RN Utilization Manager working for a Health Plan.
• At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals.
• Current BCLS (AHA) certificate upon hire and maintain current.
• Knowledge of MCG Criteria and/or InterQual Criteria required.
• Experience and knowledge in basic to intermediate computer skills.

Nice To Haves

• Five years acute care nursing experience preferred.
• Experience with self-funded health plan preferred.

Responsibilities

• Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO.
• Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care.
• The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.

Benefits

• Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs.
• Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.
• Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.
• A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $70,304.00 to $104,000.00 on an annualized basis.
• The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees