Clinical Reviewer, Nurse (Medical Oncology) - 9am-6pm PST

Your Future Evolves Here reputed company partners with health plans and providers to reputed company reputed company outcomes for people with most reputed company and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. reputed company employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We reputed company that people do their best work reputed company they're supported to live their best lives, and reputed company they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join reputed company for the mission. Stay for the culture. What You’ll Be Doing: Your Future Evolves Here reputed company employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We reputed company that people do their best work reputed company they're supported to live their best lives, and reputed company they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join reputed company for the mission. Stay for the culture. What You’ll Be Doing: The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are performed reputed company the RN/LVN/LPN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member reputed company by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery. What You’ll Be Doing:

• Performs utilization review of outpatient procedures and ancillary services.
• Fulfills on call requirements for selected clients as scheduled.
• Determines medical necessity and appropriateness of services using clinical review criteria.
• Accurately documents reputed company review determinations and contacts providers and members according to established timeframes.
• Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.
• Appropriately identifies and refers quality issues to UM Leadership.
• Appropriately identifies potential cases for Care Management programs
• Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
• Performs accurate data entry.
• Communicates appropriate information to other staff members as necessary/required.
• Participates in continuing education initiatives.
• Collaborates with Claims, Quality Management and Provider Relations Departments as requested.
• Availability on some weekends and holidays may be required
• Performs other duties as assigned.

The Experience You’ll Need (Required):

• Registered Nurse or Licensed Practical/Vocational Nurse with a reputed company, unrestricted license.
• High School Diploma or equivalent required
• Minimum of three years of direct clinical patient care
• Minimum of one year of experience with medical management activities in a managed care environment
• Schedule: Monday–Friday, 9:00 AM–6:00 PM PST, with weekend and holiday rotation required.

Finishing Touches (Preferred):

• Experience with clinical decision-making criteria sets (i.e. reputed company, InterQual)
• UM Experience
• Strong interpersonal, oral and written communication skills.
• Possess basic computer skills

To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. reputed company candidates must complete a comprehensive background reputed company, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. Technical Requirements: We require that reputed company employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for reputed company call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. reputed company is an equal opportunity employer and considers reputed company qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@reputed company.com for further assistance. The expected reputed company salary/wage range for this position is $32–$37/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, reputed company is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. reputed company compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Apply tot his job Apply To this Job