Utilization Management Review Denials Nurse, RN Job at Imperial Health Plan of California, Inc., Pasadena, CA

cWZpN3o4U3F0aGx5bVZ0R3hCdnVpclppemc9PQ==
  • Imperial Health Plan of California, Inc.
  • Pasadena, CA

Job Description

Job Description

Imperial is currently seeking a Registered Nurse with 2 to 3 years of clinical nursing background and 2 to 3 years of Utilization Review experience. The ideal nurse for this role would also be proficient in conducting peer-to-peer meetings, mitigation of denials, have a strong understanding of the preauthorization process, the revenue cycle, reducing financial risk, be able to liaise with providers/staff, and work with payers while having regulatory awareness.

About the Role

The UM Denials Specialist, RN will be responsible for managing the denials process and ensuring compliance with medical necessity criteria.

Responsibilities

  • Completes the denials process for requested services and IP hospital stays that fail to meet medical necessity consistent with MCG or CMS criteria.
  • Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Imperial Healthcare guidelines.
  • Refer cases not meeting criteria for medical necessity to Medical Director during inpatient rounds.
  • Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance and Risk Management, as appropriate
  • Develops medical summaries of denied cases for review by the Medical Directors.
  • Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
  • Identifies system delays in service to improve the provision of efficient and timely patient care.
  • Identifies process issues related to the UM concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
  • Assure quality care by adhering to standards set by the physicians.
  • Provide care education to patients in person or over the phone.
  • Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA).

Qualifications

  • Must be a Registered Professional Nurse with current licensure.
  • 2 to 3 years clinical experience required.
  • 2 to 3 years UM experience in a health care setting preferred.
  • 1-2 years background/experience with audits preferred.
  • Knowledge of OSHA, FDA, and HIPAA compliance.
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license.

Required Skills

  • Proficient in conducting peer-to-peer meetings.
  • Strong understanding of the preauthorization process.
  • Ability to liaise with providers/staff.
  • Regulatory awareness.

Job Tags

Immediate start,

Similar Jobs

Miller Bros. Const., Inc.

Construction Superintendent - Bridge Job at Miller Bros. Const., Inc.

 ...Job Description Miller Bros. Construction, Inc., is a heavy-civil contractor specializing in earthmoving, utility installation, and structure...  ..., industrial and commercial clients. Superintendent - Bridge Group Job Overview: A construction site superintendent... 

Piscataqua Landscaping & Tree Service

Loader or Skid Steer Operator (Seasonal), $21.00 - $35.00 an hour Job at Piscataqua Landscaping & Tree Service

 ...Are you a skilled and enthusiastic Snow Equipment Operator seeking a stable and rewarding career opportunity? Piscataqua Landscaping & Tree Service is currently hiring dedicated and experienced individuals to join our Snow Maintenance Division. As a Snow Equipment Operator... 

G2 Secure Staff

Cabin Provisioning Specialist Job at G2 Secure Staff

 ...The Cabin Provisioning Specialist is responsible for the oversight of Airport Services as well as developing and maintaining positive...  ...United States or possess the necessary authorization from the Immigration and Naturalization Service (INS) Must operate with the... 

OCPA

In-Home Product Tester - No Fees, No Experience, $25-$45/hr Job at OCPA

 ...Product Testers are wanted to work from home nationwide in the US to fulfill upcoming contracts with national and international companies...  ...Home Usage Test Daily Schedule (screenshots, audio recordings, videos, product journal entries, etc.) Take care of the product... 

Unifi Aviation, LLC

Airport Customer Service Agent PT - EUG Job at Unifi Aviation, LLC

 ...General information Job Title Airport Customer Service Agent PT - EUG Date Tuesday, October 7, 2025 Entity Unifi Aviation, LLC State Oregon City Eugene Base Pay Rate: $ 16.00 Full/Part Time...