Utilization Review RN - CommonSpirit Health

***This position is remote within California.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is remote within California.

Position Summary:

This position will review medical records, benefit, contractual and other guidelines to determine benefit coverage, medical appropriateness including, access, scope availability, and level of care considerations. Position updates and processes member records. Position works closely with management to coordinate member care. Position conducts inpatient and skilled nursing facility level-of-care review on a concurrent basis. Develops support tools for communication of standards and expectations.

Minimum Qualifications:

- Five (5) or more years experience working in a medical facility, hospital, or other healthcare related environment.
- Graduation from an accredited CA Registered Nursing program.
- Clear and current CA Registered Nurse (RN) license.
- Basic knowledge of CPT and ICD9/ICD10 coding.
- Excellent communication skills; able to read, write, and speak articulately, using established channels of communication and reporting relationships within the organization. Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff, families of members, outside agencies, etc.
- General knowledge of Microsoft Office applications; Excel, Word, Outlook.

Preferred Qualifications:

- Utilization management (UM)/prior authorization experience strongly preferred.

- Two (2) or more years experience in case management or IPA preferred.
- Managed care experience preferred.
- Experience with DHMSO Online, QNXT preferred.
- Completion of Case Management Certificate preferred.
- Familiarity with an electronic practice management system is preferred.