HEDIS Nurse (RN or LVN)
Rancho Cucamonga, CA 91730
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.
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
Active CA RN License
2+ years of Utilization Management experience
Skilled nursing experience is a plus!
Concurrent Review experience is a plus!