Utilization Management Nurse Specialist

Required skills: Physician with an active US licensed with experience in with medical coding (CPT/HCPCS) and managed care to conduct clinical review of claims and UM authorization requests for clinical necessity.Minimum of recent (last 2-3 years) 3-5 clinical experience in emergency dept medicine, experience in internal medicine will be considered. Experience in managed care, clinical UM case reviews. Knowledge of claims and medical coding (CPT/HCPCS codes). Proficient working in various system

< data-start="65" data-end="90">Required Skills:Active US Physician license (MD/DO).35 years of recent clinical experience (within the last 23 years) in Emergency Department (ED) Medicine.Experience in Internal Medicine is also acceptable.Experience in Managed Care environments.Expertise in conducting clinical review of claims and UM authorization requests for medical necessity.Hands-on experience with Utilization Management (UM) case reviews.Knowledge of medical coding, including CPT and HCPCS

As aPre-AuthConsultantyou will be a part of an Agile team to build healthcare applications and implement new features while adhering to the best coding development standards . Mandatory skills FACETS UM/Pre-Auth Configuration ITS/Authorization Routing Logic SQL & Rule Traceability Responsibilities: - 7 - 10 years in UM/Pre-Auth configuration within FACETS. Familiarity with UM workflows, clinical guidelines, and state mandates. Experience working with clinical/utilization management stakeho

Job Description Job Description Job Summary Manages the activities of the Data Analytics and Reporting team. Performs research and analysis of complex Clinical Data - Utilization & Care Management Data. Evaluates, writes, and presents reports and makes recommendations based on relevant findings. Uses advanced mathematical, statistical, querying, and reporting methods to develop solutions. Develops information tools, algorithms, dashboards, and queries to monitor and improve business performan