Martin's Point Health Care
501 - 1000 employees
⚕️ Healthcare Insurance
🧘 Wellness
Healthcare Insurance • Wellness
Martin's Point Health Care is a healthcare organization committed to serving its local communities through high-quality primary and specialty care services. The organization places a strong emphasis on creating a positive workplace culture, recognizing employee contributions, and fostering workforce diversity. Martin's Point Health Care offers a range of career opportunities across various departments, from healthcare providers to corporate roles, and supports employee growth through competitive compensation, development programs, and generous perks. Additionally, the company is recognized for its community impact efforts, raising significant funds for community organizations and encouraging employee volunteerism.
Utilization Review Nurse
🕒 May 26
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Martin's Point Health Care
501 - 1000 employees
⚕️ Healthcare Insurance
🧘 Wellness
Healthcare Insurance • Wellness
Martin's Point Health Care is a healthcare organization committed to serving its local communities through high-quality primary and specialty care services. The organization places a strong emphasis on creating a positive workplace culture, recognizing employee contributions, and fostering workforce diversity. Martin's Point Health Care offers a range of career opportunities across various departments, from healthcare providers to corporate roles, and supports employee growth through competitive compensation, development programs, and generous perks. Additionally, the company is recognized for its community impact efforts, raising significant funds for community organizations and encouraging employee volunteerism.
📋 Description
• Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review. • Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews. • Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues. • Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. • Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
🎯 Requirements
• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting • 2+ years of utilization management experience in a health plan UM department • Compact RN License • Certification in managed care nursing or care management desired (CMCN or CCM) • Coding/CPC desired
🏖️ Benefits
• Health insurance • Retirement plans • Paid time off
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