(RN) Prior Authorization UM Case Manager - Hybrid - 139431
UC San Diego, San Diego, CA, United States
#139431 (RN) Prior Authorization UM Case Manager - Hybrid
Location: 6256 Greenwich Drive, San Diego, CA 92122, United States
UC San Diego values and welcomes people from all backgrounds. You are encouraged to apply if you possess the required licensure and certifications and meet most qualifications.
DESCRIPTION
UC San Diego Health is a Magnet designated organization. The Prior Authorization UM Case Manager is responsible for managing the prior authorization process for various medical services, procedures, and medications. This includes ensuring that requests meet established criteria and are processed efficiently while adhering to insurance policies and medical necessity guidelines. The role involves coordinating with healthcare providers, insurance companies, and internal teams to facilitate appropriate care and manage authorization requests effectively.
RESPONSIBILITIES
Manage prior authorization processes for inpatient and outpatient services.
Coordinate with providers, insurers, and internal teams to ensure timely approvals.
Utilize evidence-based guidelines (Health Plan policies, MCG) to assess the necessity and appropriateness of requested services.
Work remotely or on-site as required, one day per week on-site.
MINIMUM QUALIFICATIONS
Graduate from an accredited school of Nursing.
RN license issued by the State of California.
Minimum two (2) years of recent RN experience in prior authorization, utilization management, or related healthcare field.
Proven background in managing prior authorization processes with preference for outpatient services and experience with insurance companies.
Well-versed in medical terminology and evidence-based guidelines such as Health Plan policies and MCG (Milliman Care Guidelines).
Proficiency with information systems and computer programs such as Word and Excel.
Excellent interpersonal and communication skills.
Ability to work within a team environment.
PREFERRED QUALIFICATIONS
BSN or Master’s Degree.
ACM and/or CCM certificate.
Epic knowledge and experience.
SPECIAL CONDITIONS
Must have access to high-speed internet when working remotely.
Must be able to work various hours and locations based on business needs.
Employment is subject to a criminal background check and pre-employment physical.
PAY & COMPENSATION
Annual Full Pay Range: $153,489 - $202,432 (prorated if appointment percentage is less than 100%).
Hourly Equivalent: $73.51 - $96.95.
LEGAL & POLICY INFORMATION
UC San Diego Health maintains a smoke and tobacco free environment. Employees may be subject to drug screening. The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.
Misconduct disclosure requirement: Final candidate accepting an offer must disclose any administrative or judicial decisions within the last seven years that determined misconduct; or filing an appeal of a finding of substantiated misconduct with a previous employer. Please refer to UC policies for definitions of misconduct.
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Location: 6256 Greenwich Drive, San Diego, CA 92122, United States
UC San Diego values and welcomes people from all backgrounds. You are encouraged to apply if you possess the required licensure and certifications and meet most qualifications.
DESCRIPTION
UC San Diego Health is a Magnet designated organization. The Prior Authorization UM Case Manager is responsible for managing the prior authorization process for various medical services, procedures, and medications. This includes ensuring that requests meet established criteria and are processed efficiently while adhering to insurance policies and medical necessity guidelines. The role involves coordinating with healthcare providers, insurance companies, and internal teams to facilitate appropriate care and manage authorization requests effectively.
RESPONSIBILITIES
Manage prior authorization processes for inpatient and outpatient services.
Coordinate with providers, insurers, and internal teams to ensure timely approvals.
Utilize evidence-based guidelines (Health Plan policies, MCG) to assess the necessity and appropriateness of requested services.
Work remotely or on-site as required, one day per week on-site.
MINIMUM QUALIFICATIONS
Graduate from an accredited school of Nursing.
RN license issued by the State of California.
Minimum two (2) years of recent RN experience in prior authorization, utilization management, or related healthcare field.
Proven background in managing prior authorization processes with preference for outpatient services and experience with insurance companies.
Well-versed in medical terminology and evidence-based guidelines such as Health Plan policies and MCG (Milliman Care Guidelines).
Proficiency with information systems and computer programs such as Word and Excel.
Excellent interpersonal and communication skills.
Ability to work within a team environment.
PREFERRED QUALIFICATIONS
BSN or Master’s Degree.
ACM and/or CCM certificate.
Epic knowledge and experience.
SPECIAL CONDITIONS
Must have access to high-speed internet when working remotely.
Must be able to work various hours and locations based on business needs.
Employment is subject to a criminal background check and pre-employment physical.
PAY & COMPENSATION
Annual Full Pay Range: $153,489 - $202,432 (prorated if appointment percentage is less than 100%).
Hourly Equivalent: $73.51 - $96.95.
LEGAL & POLICY INFORMATION
UC San Diego Health maintains a smoke and tobacco free environment. Employees may be subject to drug screening. The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.
Misconduct disclosure requirement: Final candidate accepting an offer must disclose any administrative or judicial decisions within the last seven years that determined misconduct; or filing an appeal of a finding of substantiated misconduct with a previous employer. Please refer to UC policies for definitions of misconduct.
#J-18808-Ljbffr