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Job Summary and Responsibilities

As a Utilization Management RN, you will be crucial in ensuring accurate and compliant medical necessity decisions. Your responsibilities include reviewing medical records, authorizing services, and preparing cases for physician review. You’ll work closely with both Pre-Service and In-Patient Utilization Management teams to ensure appropriate and cost-effective care.

Key functions involve:

- Authorization Review: Proactively, concurrently, or retroactively reviewing referral authorization requests, gathering necessary information, and escalating to the Medical Director when needed.

- Compliance & Accuracy: Meeting turnaround times and accuracy standards.

- Provider Network: Ensuring authorized services are with contracted providers and coordinating with contracting for new agreements.

- Care Coordination: Identifying cases for additional case management and collaborating with internal departments to coordinate patient care.

- Quality & Cost-Effectiveness: Adhering strictly to utilization management policies to promote quality, cost-effective care.

- Denial Notice Composition: Drafting compliant, clear, and member-specific denial letters in accordance with federal, state, and health plan regulations, as well as NCQA standards.

This role requires strong attention to detail, adherence to regulatory guidelines, and a commitment to superior customer service in line with CommonSpirit’s values. You will function as a UM nurse reviewer, applying clinical expertise to ensure appropriate healthcare utilization.

***This position is work from home** **within California** **, preferrably within San Luis Obispo County.

Job Requirements

Minimum Qualifications:

- Minimum of 3 years’ recent clinical experience.

- Graduate of an accredited RN Program.

- Clear and current CA Registered Nurse (RN) license.

- Knowledge of nursing theory and ability to apply or modify as appropriate.

- Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits.

- Knowledge of legal and ethical considerations related to patient information, PHI and HIPAA regulations.

Preferred Qualifications:

- Prior Utilization Management (UM) experience strongly preferred.

- Bachelors of Nursing (BSN) preferred.

Where You'll Work

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

One Community. One Mission. One California (https://youtu.be/RrPuiSnALJY?si=pvQgPZ6ZWZM60TPV)

Pay Range

$47.41 - $70.52 /hour

We are an equal opportunity/affirmative action employer.