Utilization & Claims Review Nurse (RN) ** Remote for CA residents **

Overview: Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Utilization & Claims Review Nurse (RN). • ** Candidate must be authorized to work in USA without requiring sponsorship *** • *************************************************************** • ** Location: 100% Remote for California Residents • ** Duration: 3 months contract w/ possibility of extension Notes: • 100% remote role. • Shift: Monday - Friday, 8:00am - 4:30pm. Description: • Perform clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal criteria. • Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance. • Prepare and present cases to Medical Director (MD) for medical director oversight and medical necessity determination and communicate determinations to providers and/or members in compliance with federal and accreditation requirements. • Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. • Triages and prioritizes cases to meet required turnaround times. • Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. • Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary. • Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives. • Other duties as assigned. Qualifications: • Requires a current CA RN license. • Typically, requires a college degree or equivalent experience and prior relevant experience In Post Service/Claims Review, Prior Auth Experience or Outpatient Claims experience. • Must have Utilization Review experience. • Knowledge of CPT, ICD-10, HCPCs and provider billing practices. Preferred Qualifications: • Experience with MCG or InterQual Guidelines, preferred. • Demonstrate the ability to act independently using sound clinical judgement. • Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business-based turnaround times. • Demonstrated efficient time management techniques and skills. • ***************************************************************** I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you. Satwinder “Sat” Singh Lead Technical Recruiter Company Overview: Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward. Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws. Apply tot his job