Previous Job
Previous
FEP PPO Utilization review nurse
Ref No.: 18-00299
Location: Rancho Cordova, California
Position Type:Contract
Start Date: 04/06/2018
FEP PPO Utilization Review Nurse- Rancho Cordova, CA Contract Opportunity!
 
Day to Day Responsibilities of this Position and Description of Project:
Review medical records for medical necessity of admit/continued stay at acute hospital and lower level of care (ARU, SNF, LTAC, Hospice)
Perform reviews, enter into authorization systems, notify facility, provider and member of decision in a timely manner
Prepare cases for review by physician advisor 
Works with FEP CM and facility CM for timely discharge planning/transfer
Works closely with physician advisors to ensure appropriate level of care
Identifies cases for CM referral
Calls facilities for clinical review and/or discharge information
 
Internal/External Groups with which the Candidate will interface with: FEP PPO Non-Clinical Staff, prior authorization and Care Management Teams as well as CS and Claims
Will this candidate interface with IT and business teams? If so, which ones?  
How does this project impact the line of business or as a whole?  
Required Skills (top 3 to 5/ non-negotiables): What you like to see on resumes? (nice to have)
1. Minimum 3-5 years Acute Care Experience 1. Previous experience in utilization management preferred.
2. Strong Computer Skills related to Windows-based programs and applications 2. Medical Coding- Esp. ICD 10
3. Good Communication Skills 3. Previous insurance industry experience
4. Critical thinking/organization 4.  
5. Medical record review/documentation skills 5.  
Disqualifiers or Dislikes on Resumes: Must be a registered Nurse in the State of CA, with an Active Unrestricted License
Education Requirement: AS Degree Nursing, BSN preferred
Required Testing:  
Software Skills Required: IE/chrome, word, excel, outlook
Required Certifications: Active California Registered Nurse