Hero Panel Bg

Search Jobs

Nurse RN 5 - 90485

El Dorado Hills, CA 95762

Employment Type: Contract Job Number: 9020380 Pay Rate: Pay Rate: $67.30 - $68.73 per hour

Job Description


Nurse RN 5


Job Summary Perform clinical claim reviews and initial determinations using evidence-based guidelines. This role involves reviewing claims for medical necessity, coding accuracy, and compliance;presenting cases for further oversight;documenting decisions in line with regulatory standards;and prioritizing cases to ensure timely resolution while providing appropriate referrals.

Responsibilities
  • Perform clinical claim reviews and first-level determination approvals for members.
  • Review claims for medical necessity, coding accuracy, policy, and contract compliance.
  • Prepare and present cases for medical director oversight and communicate determinations to providers and members.
  • Develop and review documentation and correspondence in compliance with regulatory standards.
  • Triager and prioritize cases to meet required turnaround times.
  • Identify quality of care issues and intervene as clinically appropriate.
  • Provide referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments.
  • Assist in standardizing retro claims review processes from a clinical perspective.
  • Perform other related duties as assigned.

Requirements
  • Current CA RN License.
  • Bachelor s degree or equivalent experience.
  • Prior experience in post-service claims review, prior authorization, or outpatient claims review.
  • Knowledge of CPT, ICD-10, HCPCs, and provider billing practices.

Skill
  • Ability to act independently using sound clinical judgment.
  • Proven ability to manage multiple tasks while prioritizing cases effectively.
  • Efficient time management and workflow skills.

Summary Qualification
  • Holds a current CA RN License.
  • Possesses a bachelor s degree or comparable experience.
  • Demonstrated expertise in clinical claims review and documentation.
  • Experience with utilization review processes and adherence to regulatory standards.


Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Apply Online Apply with LinkedIn Apply with Facebook Apply with X

Send an email reminder to:

Share This Job:

Related Jobs:

Login to save this search and get notified of similar positions.

About El Dorado Hills, CA

Ready to launch your career in the vibrant El Dorado Hills, California area? Nestled in the picturesque Sierra Nevada Foothills, this region seamlessly blends scenic beauty with flourishing job opportunities. From the captivating views of Folsom Lake and the nearby Eldorado National Forest to the thriving arts scene at the renowned Harris Center for the Arts, there's no shortage of inspiration here. Explore career possibilities in tech companies like Intel, enjoy local delicacies at the El Dorado Hills Town Center, or unwind with a stroll along the historic El Dorado Trail. Embrace the charm and endless potential of El Dorado Hills - your dream job could be just a click away!