Utilization Management RN
Where
- San Antonio, TX
What you'll be doing
- Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines. Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Identifies and refers all potential quality issues to the clinical quality management department, and suspected fraud and abuse cases to compliance department. Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication. Identifies and refers potential cases to disease management and case management. Performs all other related duties as assigned.
What your background should be
- Two years of experience in managed care or five years of experience as an RN. Current RN license, applicable for practice in the applicable state. Previous prior authorization experience preferred. Utilization review/management experience preferred. ICD-9, CPT coding knowledge/experience preferred. InterQual or Milliman knowledge/experience preferred.
Required Schooling / Training
- Not specified
Who is the client company
- This is a diversified health care company that serves the markets for health benefits and services worldwide.
- If you are interested in this position, send your resume to apply@kochdavis.com
