Utilization Review RN
Company: Dignity Health
Location: Rancho Cordova
Posted on: June 20, 2022
**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
*****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.
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
* Other duties as assigned.
- 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
- Supervisory experience preferred.
- Physician group experience preferred.
- HMO/Managed Care experience preferred.
- Familiarity with an electronic practice management system is
CommonSpirit Health--- is an Equal Opportunity/Affirmative Action
employer committed to
a diverse and inclusive workforce. All qualified applicants will be
employment without regard to race, color, religion, sex, sexual
identity, national origin, age, disability, marital status,
ancestry, veteran status, genetic information, or any other
by law. For more information about your EEO rights as an
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
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
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