Utilization Review RN - PHMI EE Benefits in Ontario, CA at Prime Healthcare

Date Posted: 4/28/2021

Job Snapshot

Job Description

Responsibilities Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness. 



Education and Work Experience

Required qualifications:

  1. Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.
  2. Minimum 3 years RN Utilization Manager working for a Health Plan.
  3. At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals.
  4. Current BCLS (AHA) certificate upon hire and maintain current.
  5. Knowledge of MCG Criteria and/or InterQual Criteria required.
  6. Experience and knowledge in basic to intermediate computer skills.
Preferred qualifications:

  1. Five years acute care nursing experience preferred.
  2. Experience with self-funded health plan preferred.

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf