1 Utilization Management (UM) Denials Nurse Job in Palm Springs, CA
Desert Oasis Healthcare is Hiring an Utilization Management (UM) Denials Nurse Near Palm Springs, CA
- Review denial authorization requests to confirm accuracy and confirm that denial is substantiated with supporting documentation and that the appropriate criteria is cited.
- Obtain necessary documentation to support denial determinations and/or makes recommendation on what additional documentation would be helpful to support denial decision.
- Communicate identified discrepancies and/or concern to the Medical Directors, physician reviewers or Utilization Management (UM) staff in order to facilitate timely letter creation and mailing process.
- Communicate upcoming authorization expiration of turn-around times to the referral distributors to ensure that referral authorizations are processed within established timeframes.
- Assess clinical documentation to confirm denial decisions match the cited criteria. Confirm that the medical reviewer’s decision is accurately documented within EZ CAP notes.
- Collaborate with Medical Directors, physician reviewers, and other UM staff to resolve questions pertaining to denial decisions and/or letter template programming.
- Review referral authorization requests and issue approval when appropriate in accordance with the established with organizational and departmental policies and procedures.
- Obtain medical necessity criteria utilizing appropriate hierarchy and in accordance with established organizational and departmental policies and procedures.
- Create and process denial letters in accordance with departmental policies and procedures, DOHC business rules and established turnaround times.
- Performs other duties as assigned.
- Graduate of an accredited nursing program.
- Current California Licensed Vocational Nurse Registered Nurse (LVN) license or Registered Nurse (RN) license.
- 3 years progressive clinical nursing experience. 1 year of Quality or Utilization Management (UM) experience, preferred.
- Knowledge of basic nursing practices and protocols.
- Knowledge of EZ CAP and NextGen, preferred.
- ICU and Medical-Surgical background, preferred.
- Must be able to work independently and possess strong clinical skills.
- Detailed oriented and well-organized. Ability to manage time effectively and prioritize tasks to meet established deadlines.
- Ability to communicate effectively with individuals within all levels of the organization, patients, providers, vendors and others.
- At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.
Job Summary
Full Time
Ambulatory Healthcare Services
$90k-114k (estimate)
05/12/2024
07/11/2024
mydohc.com
INDIO, CA
200 - 500
1981
RANDY VAUGHN
$10M - $50M
Ambulatory Healthcare Services
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About Desert Oasis Healthcare
Desert Oasis Healthcare is committed to the provision and facilitation of the highest quality medical care to the residents of the desert communities. We will strive to be an organization which provides excellence in every encounter. As a result, we will be recognized by: Our patients as their care givers of choice; Our employees as their employer of choice; Our provider and health plan partners as their health care network of choice. Desert Oasis Healthcare is a non-discriminate (Religious, Cultural, Sexual, Ethnic) Health Care Provider. In 1981, Desert Medical Group Inc. introduced to the Co...achella Valley a full service medical facility, providing the community with all their health care needs from newborn to senior care. Today, we are Desert Oasis Healthcare - a team of highly skilled primary care physicians and ancillary providers with services conveniently located throughout the desert communities. Our many locations include Palm Springs, Bermuda Dunes, Indio, Rancho Mirage and Yucca Valley. Desert Oasis Healthcare's services include access to 4 Immediate Care Centers - Indio, Palm Desert, Palm Springs and Yucca Valley. We also offer an award winning Outreach Services Department that is committed to educating individuals on how to apply the principles of preventative health care in their daily lives, resulting in improved health. Desert Oasis Healthcare accepts most HMO's, private insurance, Medicare and private pay patients. We are affiliated with every hospital in the Coachella Valley, which includes Eisenhower Memorial Hospital, Desert Regional Medical Center, John F. Kennedy Memorial Hospital and Hi-Desert Medical Center
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