Non-Clinical - Nurse Coordinator - E-Talent network : Job Details

Utilization Review NurseRemote2 month contract with probable extensionJob Description:Ensuring appropriate, cost-effective, and high-quality care for New Century Health Plan membersConducting utilization management (UM) activities in accordance with health plan policies and regulatory guidelinesIdentifying and reporting Potential Quality Issues (PQI) and supporting Provider Dispute Resolution (PDR) processes to ensure compliance and foster provider satisfactionCompleting other duties as assignedWe're seeking a highly qualified candidate with: A BSN or MSN degree, required Current valid California RN license, required Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care Knowledge of Medicare Advantage regulatory guidelines, including CMS regulations Experience with Potential Quality Issues (PQI) identification and reporting Familiarity with Provider Dispute Resolution (PDR) processes Strong clinical assessment and critical thinking skills Proficiency in electronic health records (EHR) and utilization management software Excellent written and verbal communication skillsAll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.