- Full Time/Contract
- Pasadena, CA
UM Review Nurse – RN
(Managed Care/Medical Group)
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.
- 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.
- Current California RN
- 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!
$39 – $40.50hr