Utilization Review RN

Overview:

Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California.  Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.  

***This position is hybrid in-clinic/hospital and work from home.

Position Summary:

This position will review medical records, benefit, contractual and other guidelines to determine benefit coverage medical appropriateness including access, scope availability, and level of care considerations. Position updates and processes member records. Position Assists Member Services Dept Claim Dept. and Physician and ancillary Providers and Health Plans with issues that require medical interpretation research or clarification. Position performs audits of various medical records and documentation as needed. Position works closely with Primary Care and Specialist physicians Medical Director ancillary providers and case management to coordinate member care. Position performs function of a clinical resource to non-licensed staff. Develops support tools for communication of standards and expectations.

Minimum Qualifications:

• Five (5) years of experience as an RN
• Two (2) years of experience in a medical insurance environment
• Bachelors degree (BA or BS) or equivalent education and experience
• Current California Registered Nurse (RN) license
• Competent in use of Microsoft word excel and window
• Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment
• 45wpm and 10 key by touch required
• Familiar with multiple medical specialty procedures and diagnoses

Preferred Qualifications:

• Supervisory experience preferred
• Physician group experience preferred
• HMO/Managed Care experience preferred
• Familiarity with an electronic practice management system is preferred

#carecoordination