Medical Referral Nurse Job

MEDICAL REFERRAL NURSE needed for a CONTRACT opportunity with Yoh's client located in San Francisco, CA

THE BIG PICTURE - TOP SKILLS SHOULD YOU POSSESS:

- Utilization Review experience
- Knowledge of Managed Care

WHAT YOU'LL BE DOING:

- Perform Utilization Review activities prospectively or post-service (retrospective) for elective/urgent hospital admissions and outpatient services with complete and timely reports to members, providers and health plans as requested.
- Review the authorization request and medical information provided by the requesting provider for medical necessity and appropriateness, comparing information to current medical care criteria by health plan and as specified by CMS, CDC, NCQA and DMHC requirements
- Review all cases against the division of financial responsibility (DOFR), Health Plan Ancillary Grids and Ancillary lists to ensure appropriate vendors are utilized for payment of services
- Follow out-of-network procedures working with Contract Specialist to obtain provider specific letters of agreement for services for OON cases as required
- Generate required notification to patients and providers, both verbal and written
- Formulate appropriate denial letter language in accordance with Industry Collaborative Effort (ICE) and health plan requirements

WHAT YOU NEED TO BRING TO THE TABLE:

- Current California RN license
- Must have a minimum of three to five years (3-5) nursing experience in an outpatient setting, Case Management or inpatient setting
- Minimum of three years utilization review or managed care experience
- Strong verbal and written communication skills
- Computer skills essential: Internet searches, MS Office, InterQual, type a minimum of 50 wpm
- Must be able to maintain confidentiality of medical, product and company information

BONUS POINTS! OTHERWISE KNOWN AS PREFERRED QUALIFICATIONS:

- CCM, CDMS, CRC, CRRN, CHON, CPUR preferred
- Familiarity with ICD-9, CPT and HCPCS codes preferred

WHAT ARE YOU WAITING FOR? APPLY NOW!

RECRUITER: Jennifer Andersen

Yoh, a DayJ2W: PROF

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