Description:

• Ensures proper procedure and diagnosis codes are reviewed for submitted procedures/claims.

• Solicits support from SME's, leads, and managers as appropriate

• Triages and prioritizes cases to meet required Turn-around times

• Expedites access to appropriate care for members with urgent needs

• Prepares and submits clinical review cases to Medical Director (MD) for medical director oversight and necessity determination

• Communicate determinations to providers and/or members to in compliance with state, federal, and accreditation requirements

• Develops and reviews member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards

• 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.

Skills:

Acute Care, Concurrent Review, Home Health, Long Term care, Health plan, Utilization Review, Utilization Management, Interqual

Additional Skills & Qualifications:

• CA RN License required

• 5+ years of RN or healthcare experiences to be considered

• This position will work with long term care facilities to help facilitate UR / UM. Will manage a case load of 11-15 cases per day.

• Team consists of 3 nurses. Candidate brought on will be the 4th.

Experience Level:

Entry Level

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent

• Maintaining an inclusive environment through persistent self-reflection

• Building a culture of care, engagement, and recognition with clear outcomes

• Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.