Compliance Analyst - RN

at  Robert Half

We are offering a role for a Compliance Analyst RN based in Monterey Park, California, United States. This position is a short term contract employment opportunity within the field of financial services. As a Compliance Analyst, you will be responsible for coordinating and maintaining all compliance administrative activities, communicating with delegated entities and auditors, and reviewing audit submissions.

• The Compliance Specialist RN will facilitate, coordinate, and approve medically necessary referrals that meet established criteria
• Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status
• Generates approval, modification, and denial communications, to include member and provider notification of referral determination
• Actively monitors for admissions in any inpatient setting
• May performs telephonic and/or on-site admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan
• Works with the UM Director and Medical Director on case reviews for pre-service, concurrent, post-service, retrospective claims medical review, and some appeals
• Acts as a department resource for medical service requests /referral management and processes
• May receive incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps
• Follows up with caller to provide response or resolution steps
• Answers all inquiries in a professional and courteous manner
• Promote and support team engagements, programs, and activities to create and ensure a positive and productive workplace environment
• Graduate from an Accredited School of Nursing.
• Bachelor’s degree in Nursing preferred.
• Active California LPN/LVN or RN license.
• Three (3) years of utilization management experience in a managed care setting.
• Two (2) years of clinical nursing experience
• Knowledge of utilization management principles and healthcare managed care.
• Experience with medical decision support tools (i.e., InterQual, NCDs, LCDs) and government sponsored managed care programs.
• Computer literacy on Microsoft Office products.
• Patient advocacy focus.
• Knowledge of required regulatory timelines to ensure department compliance with State and other regulatory contracts.
  Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.
  Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app and get 1-tap apply, notifications of AI-matched jobs, and much more.
  All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.
  © 2024 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking “Apply Now,” you’re agreeing to Robert Half’s Terms of Use