RanchoCordovaRecruiter Since 2001
the smart solution for Rancho Cordova jobs

Utilization Review RN

Company: Dignity Health
Location: Rancho Cordova
Posted on: June 20, 2022

Job Description:

**Utilization Review RN**

Dignity Health Medical FoundationRancho Cordova, California

**Requisition ID** 2022-222572 **Employment Type** Full Time **Department** Utilization Review **Hours/Pay Period** 80 **Shift** Day **Weekly Schedule** Monday-Friday (8:00 AM-5:00 PM) **Remote** No **Category** Case Management and Social Work

**Overview**

*****This position will allow some remote/work from home options in the Greater Sacramento region.**

Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.

**Responsibilities**

**Position Summary:**

The Utilization Review RN will review medical records, benefit, contractual and other guidelines to determine benefit coverage, medical appropriateness including, access, scope availability, and level of care considerations. Position updates and processes member records. Position Assists Member Services Dept, Claim Dept. and Physician and ancillary Providers and Health Plans with issues that require medical interpretation, research or clarification. Position performs audits of various medical records and documentation as needed. Position works closely with Primary Care and Specialist physicians, Medical Director, ancillary providers and case management to coordinate member care. Position performs function of a clinical resource to non-licensed staff. Develops support tools for communication of standards and expectations.

Responsibilities may include:

* Reviews and approves prior authorization requests for medical necessity within NCQA timelines using the predetermined criteria provided by the different plans and UM Committee criteria.

* Responsible for timely and appropriate denial letters that meet standards, coordinating with other team members, printing and distribution of letters.

* Reviews correct CPT, HCPC, ICD-9 codes for each referral.

* 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.

* Other duties as assigned.

**Qualifications**

**Minimum Qualifications:**

- Minimum of five (5) years experience as an RN. Two (2) years experience in a medical insurance environment.

- BS or BA, or equivalent education and experience.

- Clear and current CA RN license.

- Competent in use of Microsoft Word, Excel, and Windows. Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment. 45wpm and 10 key by touch required.

- Familiar with multiple medical specialty procedures and diagnoses.

**Preferred Qualifications:**

- Supervisory experience preferred.

- Physician group experience preferred.

- HMO/Managed Care experience preferred.

- Familiarity with an electronic practice management system is preferred.

\#HelloCareCoordination

**Equal Opportunity**

CommonSpirit Health--- is an Equal Opportunity/Affirmative Action employer committed to
a diverse and inclusive workforce. All qualified applicants will be considered for
employment without regard to race, color, religion, sex, sexual orientation, gender
identity, national origin, age, disability, marital status, parental status,
ancestry, veteran status, genetic information, or any other characteristic protected
by law. For more information about your EEO rights as an applicant,
pleaseclick here. (https://tbcdn.talentbrew.com/company/35300/img/v1\_0/EEOLawPoster.pdf)

CommonSpirit Health--- will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c).
External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA).
CommonSpirit Health--- participates in E-Verify.

Dignity Health is an Equal Opportunity/ Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law.

Keywords: Dignity Health, Rancho Cordova , Utilization Review RN, Healthcare , Rancho Cordova, California

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Log In or Create An Account

Get the latest California jobs by following @recnetCA on Twitter!

Rancho Cordova RSS job feeds