Rn Jobs

About The Position

Requirements

• Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
• For Health Net Federal Services: Must have current and active licensure or certification that permits independent assessment required.
• For Health Net Federal Services: US citizenship and current National Agency Check government security clearance required.

Nice To Haves

• Strong knowledge of appeals and utilization management principles preferred.
• 3 - 5 years of direct work experience and knowledge of the appeals process and utilization management principles in managed care/MCO environments is preferred.
• For Health Net Federal Services (Medical Management): Certified Managed Care Nurse (CMCN) within 1-1/2 Yrs required.
• REMOTE RN candidates may reside in any state but a current and active RN license from the state of California is strongly preferred.

Responsibilities

• Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members.
• Supervises day-to-day activities of utilization management team.
• Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards.
• Collaborates with utilization management team to resolve complex care member issues.
• Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management.
• Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management.
• Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers.
• Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures.
• Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
• Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones.
• Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
• Assists with onboarding, hiring, and training utilization management team members.
• Leads and champions change within scope of responsibility.
• Performs other duties as assigned.
• Complies with all policies and standards.

Benefits

• competitive pay
• health insurance
• 401K
• stock purchase plans
• tuition reimbursement
• paid time off
• holidays
• flexible approach to work with remote, hybrid, field or office work schedules