Job description
This position is remote for those living in San Diego, CA
Job Description:
Reviews contracted Medical Group’s referral requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed decision. Processes all requests within established timeframes. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters.
Refers all medical necessity denials to the physician for review. Processes denials within establishes timeframes. Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available.
Reviews requests within established timeframes for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards.
Obtains additional information for Medical Director’s review of appeals. Coordinates with health plan to meet timeframes for expedited appeals.
Contacts out of network or tertiary facilities for clinical information on patients authorized for services at the facility. Coordinates discharge needs for these members with hospital case manager.
Notifies health plan representative of potential transplants, out of area second opinions, experimental or investigational requests.
Non-clinical, office setting and onsite.
View our company website to learn more about the company and career opportunities. You may apply through company website or through Indeed.
www.scpmcs.org
SCPMCS is an Equal Opportunity Employer
Job Type: Full-time
Pay: $42.00 - $47.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Free parking
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Tuition reimbursement
- Vision insurance
Physical setting:
- Office
Schedule:
- Day shift
Application Question(s):
- Are you okay with a 4/10 schedule- 6:30 am-5:00 pm?
- What are your salary expectations?
- Please list 2-3 dates and time ranges that you could do an interview.
- Are you okay with working onsite for at least 90 days?
- Will you be able to reliably commute or relocate to San Diego, CA 92121 for this job? (Deal breaker)
Education:
- Associate (Preferred)
Experience:
- Nursing: 2 years (Preferred)
- Case management: 1 year (Preferred)
- Utilization review: 1 year (Preferred)
- Managed care: 1 year (Preferred)
License/Certification:
- California RN License (Required)
Work Location: Remote
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