UM Review Nurse – RN

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  • 18-00273
  • Full Time/Contract
  • Case Management
  • Pasadena, CA
Job Description
CLIENT COMPANY OVERVIEW.
Our client is an innovative network of providers delivering innovative and quality care to patients from Northern to Southern California.

JOB TITLE
UM Review Nurse RN

JOB SUMMARY
The Utilization Nurse is responsible to assure health care services are available to Medical Group members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.

JOB DUTIES

  • Provides first level clinical review for all outpatient, planned inpatient and ancillary services requiring authorization. Performs retrospective chart review as indicated.
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
  • Refers those requests that do not meet medical criteria review to the Medical Director or Physician Advisor for second level review and determination.
  • Completes data entry and correspondence as necessary for each review.
  • Answers Utilization Management directed telephone calls; managing them in a professional and competent manner.
  • Processes all prior authorizations to completion utilizing appropriate review criteria.
  • Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity.
  • Acts as liaison between the IHHMG members, network providers Provider Relations Department for contracted health plans.
  • Screens and refers appropriate health plan members for short term or complex case management, disease management, or other care management strategies as applicable.
  • Maintains knowledge of and is compliant with current UM Plan and policies & procedures.
  • Performs quality improvement activities and maintains current quality improvement document as directed.
  • Perform other duties as assigned.

QUALIFICATIONS

  • Current California RN License
  • 3+ years of nursing experience in an acute care hospital setting
  • 3+ years of managed care and utilization review experience
  • Experience with clinical review
  • Spanish speaking or other second language a plus!

POSITION CLASSIFICATION & COMPENSATION

  • Full-Time/Contract to Hire
  • $39 – $40.50hr

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