Esolutions Inc Rancho Cordova , CA 95670
Contract 3+ Months
Performs prospective reviews and first level determination approvals for members using FEP and BSC evidenced based guidelines, policies and nationally recognized clinal criteria across FEP's line of business. Ensures diagnosis matches ICD 10 codes.
Effectively manage utilization trends to ensure that members receive clinical services at the most appropriate and cost-effective level of care.
Effectively communicates with members and providers on their PSR authorization requests
Triages and prioritizes cases to meet required, regulatory turn-around times. Expedites access to appropriate care for members with urgent needs using expedited review process.
Develops determination recommendations. If the recommendation is to deny a specific treatment, presents cases to Medical Director (MD) as required.
Communicate determinations to providers and/or members to be in compliance with state, federal and accreditation requirements.
Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
Identifies potential Third Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.
Generally requires moderate to thorough experience in nursing, health care or related field. (5 years)
Current active unrestricted CA RN License. Bachelor of Science in Nursing or advanced degree preferred.
Able to operate PC-based software programs including proficiency in Word and Excel. Strong clinical documentation skills, independent problem identification and resolution skills
Must Have: Must be a registered Nurse in the State of CA, with an Active Unrestricted License Big gaps in employment.
ASN Degree Nursing, BSN preferred
Required Skills (top 3 to 5/ non-negotiables):
Would like to see on resumes? (nice to have)
Clinical Documentation Specialty
Varied clinical background
Strong Computer Skills related to Windows-based programs and applications
Previous experience in prior authorization or utilization management preferred.
Good Communication Skills
Minimum 3-5 years Acute Care Experience
Vidhwan Inc. DBA E-Solutions- E-Verified Employer
2 N. Market St., #400, San Jose, CA, 95113
Tel (US): Fax:
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