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SalaryPosition: Utilization Management Nurse
Location: REMOTE in CA
Duration: 6+ Months Contract with possible extension
Pay Rate: $50/hr
Relocation Expenses/ Assistance: NO
Schedule: M-F: 8:00 – 5:00p pacific
Job Description:
- Review post service inpatient medical claims using the ClaimLogiQ (CLQ) system. Will need to work between multiple systems.
- Focus on Facility Medical Reviews (FMR) for length of stay and level of care reviews per MCG guidelines.
- Reviewing medical records to determine if the facility is appropriate building for the hospital stay.
- If unable to approve, then prep for Medical Director review within CLQ.
- Trauma reviews based on county or ACS guidelines. Review of the medical records to determine that the trauma services being billed meet the county or ACS guidelines. If unable to approve, then prep for Medical Director review within CLQ.
- Implant reviews based on Implant Reference List guidelines (internal guideline), review to see if appropriate to pay as a Schedule Category 1 or if no applicable schedule applies. This review is based on the information on the spreadsheet.
- Possibly trained on additional FCR reviews if appropriate.
Job Requirement:
- RN License required.
- Current CA RN
- Prior experience in medical insurance industry
- Knowledge of provider billing, CPT codes, ICD-10, HCPCS and billing practices
- Demonstrate ability to act independently using sound clinical judgement
Preferred:
- MCG experience
- Post Service or Prior authorization experience
- Excellent communication and organizational skills
- Strong computer navigation skills
- Experience in a fast paced, production and quality environment
Job Types: Full-time, Contract, Temporary
Pay: $50.00 per hour
Benefits:
- Health insurance
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Experience:
- Prior Authorization: 2 years (Required)
License/Certification:
- Registered Nurse (Required)
Work Location: In person
