RN Utilization Review remote - MediGold Health Plan

MediGold (https://medigold.com/) is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

RN Utilization Review MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member's family and other resources as appropriate. Assist in the development of the Plan's UM Program and the review of the Plan's Medical Management Plan.

Participates in designated committees and task forces according to the UM Program and at the direction of the Sr. Director of Medical Management. Coordinates with the utilization review, case management, discharge planning staff within network facilities. Coordinates with Medical Director/Associate Medical Directors on case-specific issues. Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues. Documents and communicates to QM staff appropriately all identified quality concerns related to Members. All other duties as assigned.