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Registered Nurse - Utilization Manager in Rancho Cordova, CA at APEX Systems

Date Posted: 5/15/2019

Job Snapshot

Job Description

Job #:  950970
Apex Systems is actively looking for a RN Utilization Management to join one of our healthcare client in Rancho Cordova, CA. For immediate consideration please send your resume to Mukti Patel at
Contract: 3+ month to hire
Start Date: April 15
Location: Rancho Cordova, CA
Shift: 8AM-5PM Monday to Friday
Pay Rate: Negotiable
Minimum 3-5 years Acute Care Experience

•Previous experience in prior authorization or utilization management preferred

  1. Performs prospective reviews and first level determination approvals for members.
  2. Ensures diagnosis matches ICD 10 codes.
  3. 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.
  4. Develops determination recommendations. If the recommendation is to deny a specific treatment, presents cases to Medical Director (MD) as required.
  5. Communicate determinations to providers and/or members to be in compliance with state, federal and accreditation requirements.
  6. Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
  7. Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
  8. Identifies potential Third Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
  9. Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
  10. Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.

EEO Employer
Apex is an Equal Employment Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at 844-463-6178-6178.