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Nursing, Pharmacy, & Health Services - Utilization Management

Company: ICONMA, LLC
Location: Rancho Cordova
Posted on: June 19, 2022

Job Description:

Ensures accurate and timely clinical review of claims requiring review.
The Post Service Clinical Review RN performs claim reviews utilizing Client evidenced based guidelines, medical policies, and nationally recognized clinical criteria.
The successful RN candidate will review post service clinical claim review and provider appeals for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.
The RN prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination, if needed.
RN triages and prioritizes their caseload to meet required regulatory turn-around times.
The RN communicates determinations to the members and providers in compliance with state, federal and accreditation requirements.
The RN ensures the coding and diagnosis reviewed with the appeals submitted match the services being requested/billed for the member.
The RN will refer members for Case Management as needs are identified.


Bachelor of Science in Nursing or advanced degree preferred and 3 years of prior relevant experience.
Knowledge of CPT, ICD-10, HCPCS and billing practices.
Demonstrate the ability to act independently using sound clinical judgement.
Demonstrate strong verbal and communication skills.
Proficient skills with Microsoft Office Suite.
RN license.

As an equal opportunity employer, ICONMA prides itself on creating an employment environment that supports and encourages the abilities of all persons regardless of race, color, gender, age, sexual orientation, citizenship, or disability

Olivia Ojiaku

M: (248) 515-6856

Keywords: ICONMA, LLC, Rancho Cordova , Nursing, Pharmacy, & Health Services - Utilization Management, Executive , Rancho Cordova, California

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