Spectrum Healthcare Services, a healthcare recruiting agency, is seeking a Registered Nurse to fill a Remote Utilization Review Case Manager position in Folsom, CA.

Job Summary
The Utilization Review (UR) Case Manager is responsible for evaluating the medical necessity of inpatient and outpatient services, ensuring appropriate length of stay, and facilitating timely and accurate authorization processes. This role supports the objectives of the Case Management department by promoting efficient, cost-effective, and quality patient care.

Essential Duties and Responsibilities:

• Medical Necessity Evaluation:
  Assess and determines the medical necessity of proposed inpatient and outpatient services using established clinical criteria (e.g., InterQual, Milliman).
• Authorization Management:
  Obtain and verify insurance authorizations, ensuring correct authorization numbers, levels of care, and date ranges are documented.
• Clinical Documentation Review:
  Conduct thorough chart reviews to ensure clinical documentation aligns with the requested level of care.
• Appeals Management:
  Prepare and submit appeals for denied cases, collaborating with the interdisciplinary team and insurance providers to resolve issues.
• Collaboration and Communication:
  Work closely with physicians, nursing staff, admissions, and claims teams to ensure seamless coordination of care and accurate billing.
• Compliance and Reporting:
  Maintain accurate and timely documentation of all UR activities, adhering to departmental policies and regulatory requirements.
• Continuous Improvement:
  Participate in quality improvement initiatives, identifying trends and opportunities to enhance care delivery and operational efficiency.

Position Details

Work Setting: Remote
Job Type: Direct Hire
Shift: Days
Weekly Hours: 40
Pay Rate: $31.50-$47.00 hr.

• Education:
  Graduate of an accredited nursing program with a diploma or Associate’s degree; Bachelor of Science in Nursing (BSN) preferred.
• Licensure:
  Current Registered Nurse (RN) license in the state of practice.
• Experience:
  Minimum of 4 years of recent clinical experience in acute care settings.
• Specialized Experience (Preferred):
  Experience in prospective, concurrent, and retrospective utilization review. Clinical background in areas such as Operating Room (OR), Intensive Care Unit (ICU), Coronary Care Unit (CCU), Emergency Room (ER), or orthopedics.
• Knowledge of Workers' Compensation Claims Process:
  Familiarity with the workers' compensation system and related documentation requirements.
• Outpatient Utilization Review:
  Experience in reviewing outpatient services for medical necessity and authorization.