JOB DETAILS
LOCATION
Orange, CA
POSTED
30+ days ago

Description

Remote Utilization Management Nurse Auditor Opportunity
 
BRING YOUR PASSION FOR IMPROVING THE DELIVERY OF PATIENT CARE 
 
Our client, a progressive, successful managed care organization is looking for innovative and energetic Utilization Management nurses to join their team.
 
The Utilization Management Nurse Auditor will ensure that affiliated medical groups maintain compliance with UM and CM processes.  Working remotely, you will be part of an energetic, collaborative, and supportive compliance team. 
 
Responsibilities include:
  • Managing Health Plan reporting both routine and ad-hoc.
  • Assisting with annual oversight audit preparation and audit completion
  • Coordinating CAP responses, assuring CAP implementation and compliance
  • Ensuring regulatory compliance processes for health plan, state, and federal entities
  • Developing positive and productive working relationships with Health Plan representatives
  • Promoting compliant UM and CM processes in collaboration with Medical Groups, Data Analysts, and Delegation Oversight Team
 
Qualifications:
  • Graduate from an accredited school for nursing
  • Active California Nursing License, LVN license will be considered, RN preferred
  • 3-5 years of clinical experience required
  • 2-3 years of managed care experience
  • Minimum one year of UM audit experience with a Health Plan or MSO preferred
  • Knowledge base including DMHC, DHCS, CMS, and NCQA regulatory requirements
  • Proficient in Microsoft Office programs
  • Enjoys working in a fast-paced environment that values creative problem solving and strong interpersonal skills
 
Qualified candidates are invited to contact Emily Outhwaite for additional details.