Insight Global is looking for a Utilization Management Nurse to work for a large Healthcare company in Orange County, CA. This position is 100% telephonic and a remote position (training will be completely remote). The UM Nurse is responsible for reviewing requests received from providers, using approved protocols and criteria (i.e. State and Federal Law and Regulations Centers for Medicare and Medicaid Services (CMS), Pharmacy criteria as available, Monarch HealthCare (MHC) Clinical Practice Guidelines and criteria, Milliman Care Guidelines (current edition). When making a determination of coverage based on medical necessity, the UM Nurse obtains relevant clinical information and may consult with the treating physician, office I hospital staff, or assigned Case Manager as necessary. The UM Nurse is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider/facility as appropriate for all fully-funded lines of business. However, when the UM Nurse cannot approve the request, the UM Nurse will forward the request to the designated MHC Medical Director.
-2 years of Utilization Management/Managed Care Experience
-Active LVN license
-Excellent computer experience
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.