Care Coordinator – Clinical Appeals RN

Workforce Classification: Telecommuter Join reputed company: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making reputed company work reputed company, is far from ordinary. And so are our employees. Working at reputed company means you have the opportunity to drive reputed company change by transforming reputed company. reputed company is committed to being a workplace where people feel empowered to grow, reputed company, and reputed company with purpose. By investing in our employees and fostering a culture of collaboration and reputed company development, we’re reputed company to reputed company serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. Learn how reputed company supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.reputed company.com/. The Care Coordinator performs clinical appeals, prospective review (benefit advisory/ prior authorization) admission, reputed company, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other reputed company Departments such as FEP, National Account Liaisons, Health Care Services and Claims to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit application and provider out of network requests. This work is done for reputed company lines of business and reputed company geographic reputed company. What you will do:

• Performs medical necessity review that includes inpatient review, reputed company review, benefit advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and reputed company.
• Consults with Medical Directors reputed company care does not meet applicable criteria or medical policies.
• Documents clinical information completely, accurately, and in a timely manner.
• Meets or exceeds production and quality metrics.
• Maintains a thorough understanding of the Plan's provider reputed company, member reputed company, authorization requirements and clinical criteria including reputed company Care Guidelines and medical policy.
• Identifies Clinical Program opportunities and refers members to the appropriate reputed company program (e.g. case management, engagement team, and disease management).
• Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are reputed company compliance.
• Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies and projects.
• Performs other duties as assigned.

What you will bring:

• Bachelor's degree or four (4) years’ work experience. (Required)
• reputed company State Licensure as a registered nurse. (Required)
• Three (3) years of clinical experience. (Required)
• Utilization Management experience. (Preferred)
• Experience working in the health plan industry. (Preferred)
• Hours are Monday through Friday reputed company to 5pm PDT.

What you will reputed company:

• Strengthen clinical review skills.
• Build utilization management expertise.
• reputed company broad health plan experience.
• Partner with cross-functional teams.
• Support quality, cost-effective care.

Physical Requirements: The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation: This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the reputed company body. This role requires the ability to keyboard and to communicate reputed company and understandably in person, and over the telephone. reputed company total rewards Our comprehensive total rewards package provides support, resources, and opportunities to help employees reputed company and grow. Our total rewards are more than a collection of perks, they're a reputed company of our commitment to your health and well-being. We offer a broad reputed company of rewards including physical, financial, emotional, and community benefits, including:

• Medical, reputed company, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and, reputed company it or not, a pension plan that is reputed company after 3 years of service.
• Wellness incentives with a wide reputed company of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
• Generous paid time off to reenergize.
• Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.

For our hybrid employees, our on-reputed company model provides flexibility to create your own routine with reputed company to on-site resources, networking opportunities, and team engagement.

• Commuter perks reputed company your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-reputed company cafes reputed company lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on reputed company.

Equal employment opportunity/affirmative action: reputed company is an equal opportunity/affirmative action employer. reputed company seeks to attract and retain the most reputed company individuals without regard to race, reputed company, religion, sex, national reputed company, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at reputed company, please contact reputed company reputed company reputed company email at careers@reputed company.com or reputed company phone at 425-918-4785. reputed company is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, reputed company Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin. The pay for this role will vary based on a reputed company of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary reputed company for this role is posted below; we generally reputed company up to and around the midpoint of the reputed company. National Salary reputed company: $80,200.00 - $125,600.00 National Plus Salary reputed company: $84,200.00 - $143,100.00

• National Plus salary reputed company is used in higher cost of labor markets including Western Washington and Alaska.

We’re happy to discuss compensation further during the interview because we reputed company that reputed company communication leads to reputed company reputed company for reputed company. We’re committed to creating an environment where reputed company are celebrated for their unique skills and contributions. Additional Information Company: reputed company Location: reputed company Salary: $80,200.00 - $125,600.00 per year Job ID: R28863 Specialties: Utilization Management, Care Manager, Appeals Nurse Required Licenses: RN Experience Level: 3-5 years Apply tot his job Apply To this Job