Responsibilities

Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.
2. Minimum 3 years RN Utilization Manager working for a Health Plan.
3. At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals.
4. Current BCLS (AHA) certificate upon hire and maintain current.
5. Knowledge of MCG Criteria and/or InterQual Criteria required.
6. Experience and knowledge in basic to intermediate computer skills.

Preferred qualifications:

1. Five years acute care nursing experience preferred.
2. Experience with self-funded health plan preferred.

Pay Transparency

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $71,760.00 to $104,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days