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Prior Authorization (RN or LVN) Nurse - Medical Claims Review

Job Description

Prior Authorization (Per-Cert) Registered Nurse Case Manager

About the Job:

  1. Review referral requests (routine, urgent & stat) for various office visits, outpatient and inpatient procedures using Milliman Care Guidelines to determine medical necessity
  2. Coordinate reviews, deferrals & denials with medical director, medical groups, health plans
  3. Create denial letters based on the MD's review and guidelines
  4. Submit treatment authorization requests to health plans as needed
  5. Determine and coordinate letters of agreement with medical director & network manager
  6. Contact Health Plans to verify benefits for a member’s coverage

Job Requirements

  • CA Nursing License (Registered Nurse RN, Licensed Vocational Nurse LVN)
  • Strong PC and office abilities
  • Able to meet production quotas
  • Must have prior UM experience!

About the Agency:

Managed Care Resources, Making Careers is a Health Care Staffing Agency in the niche fields of Case Management, Utilization Management / Review, Quality Management / Assurance and Performance Improvement. MCR, Making Careers has been servicing the State of California since 1987 providing Medical Professionals to Hospitals, Medical Groups, IPAs, Health Plans, Healthcare Foundations, Home Health Departments, Medical Offices, Managed Care and Insurance Companies in search of both Permanent and Temporary Staff. Call: (310)-470-4232 or (800)-350-1471 for more information!


Job Snapshot

Employment Type Full-Time
Job Type Health Care, Nurse, Insurance
Education Not Specified
Experience At least 2 year(s)
Manages Others No
Relocation No
Industry Managed Care, Healthcare - Health Services, Insurance
Required Travel Not Specified
Job ID 30A*
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Prior Authorization (RN or LVN) Nurse - Medical Claims Review

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