HEDIS Nurse (RN or LVN)

Rancho Cucamonga, CA 91730

Post Date: 06/06/2018 Job ID: 42908 Profession: RN Case Manager

Are you an RN with case management experience? Looking to work for a large player in the Inland Empire market? This is the job for you!! This group provides full range of managed healthcare services, including the effective management of risk arrangements, for independent practice associations, medical groups, hospitals, and other managed care organizations. Company is looking for a HEDIS Nurse.

Job Activities:

Working with Hospitals, skilled nursing facilities and IPAs to review cases for IEHP members and ensure appropriate care is received

Review cases for medical necessity and appropriateness of care for skilled and long term care services

Process authorization for outpatient services and ancillary services

Discharge planning and transition of care planning

Confirming proper eligibility and authorizations were received

Reviewing denials and correcting language for appeals

Reviewing referrals received

Researching cases and steps taken

Generating reports on various cases

Suggesting corrections for future issues and cases

Communicating with Physicians as needed

Abstracting and reviewing charts

Insuring timelines were met for authorization processes

Assisting with other projects as needed

Must have:

Active CA RN License

2+ years of Utilization Management experience

Skilled nursing experience is a plus!

Concurrent Review experience is a plus!


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