UM QI and UM Review Nurse – Medical Group/IPA

Posted · Add Comment

APPLY NOW

  • 19-00168
  • Direct Placement
  • Managed Care Nursing
  • Torrance, CA
Job Description
Position

UM Review Nurse
(IPA/Medical Group)
 
Description
 
UM Review Nurse
Under the direction of the UM Manager and the Senior Director of Medical Management, as defined through the authority of the Medical Director, evaluates requests for service for medical necessity, appropriateness, and efficiency of medical services for IPA members while following regulatory guidelines, as applicable to the utilization management process. The UMRN works closely with physicians, hospitals, and health plan representatives in addition to other internal departments concerning utilization review.
 
Primary Duties and Responsibilities:

  • Following guidelines, evaluates the medical necessity, appropriateness and efficiency of medical services and procedures requested on behalf of  members
  • Accurately and comprehensively documents UM decisions based on the standards of practice and current  policies
  • Effectively provides feedback to providers concerning necessary documentation to meet referral management decision requirements
  • Communicates outcomes of review determinations to providers and members as defined by regulatory requirements
  • Coordinates cost effective care supported by evidence based clinical practice guidelines
  • Acts as a resource for staff in issues relating to the UM department
  • Telephonically interacts and communicates with other  Health System (TMHS) departments and staff, supporting continuity of care
  • Understands fiscal accountability and its impact on the utilization of resources
  • Assists UM Manager with daily operations of the department
  • Assumes responsibility for in-house referral reviews and urgent authorization request, and answers incoming ‘urgent’ telephone authorization requests
  • Understands and identifies under-utilization and over-utilization of services through the referral process
  • Works closely within the Medical Management department and other  departments to foster open interdepartmental communication and avoid disruption of efforts
  • Works closely with the UM Quality Improvement Nurse to support compliance with all health plan, state and federal requirements related to the UM process
  • Interfaces with contracted health plans, assuring timely and appropriate responses to health plan inquiries
  • Meets regulatory turn-around-times and departmental productivity goals when processing referrals
  • Assists Claims Department in determining status of retrospective claims for reimbursement
  • Support  Health System’s Values of Service, Excellence, Knowledge, Stability and Community and behaves in a manner that reflects these values
  • Demonstrates ability to effectively handle multiple tasks throughout the workday and to appropriately prioritize tasks
  • Demonstrates effective problem-solving techniques by resolving complaints and implementing effective solutions
  • Receptive to suggestions from staff members, managers and superiors
  • Adhere to the Health System’s Standards of Behavior
  • Work cooperatively with all team members to achieve departmental organizational goals  
  • Uses, protects and discloses member Protected Health Information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
  • Adhere to all Health System policies, procedures and guidelines
  • Attend and participate in staff meetings, performance improvement, workshops/seminars to enhance skills and performance effectiveness
  • Maintain a neat, clean, and orderly work area
  • Participates in department specific initiatives and department meetings.
  • Remains current with relevant healthcare requirements and the relevant professional literature
  • Follows company code of conduct
  • Complete Self-Evaluation for annual performance evaluation

  Requirements 

  • Registered Nurse with unrestricted CA license
  • Bachelor or Associate degree in nursing
  • Thorough knowledge of Registered Nurse (RN) scope of practice, current state requirements
  • Two (2) years acute hospital experience
  • 2 years managed care experiences in Utilization Management
  • Knowledge of MediCal and Medicare benefits requirements
  • Knowledge of industry approved evidence-based guidelines such as Interqual, CareEnhance® Review Manager Enterprise (CERME), and/or Milliman
  • Thorough understanding of  the Health Plan Division of Financial Responsibility (DoFR)
  • Experience with NCQA standards and review process
  • Knowledge of CMS Conditions of Participation
  • Working knowledge of Federal, State and local community resources, services and programs
  • Excellent verbal and written skills required
  • Must read, speak and write English fluently
  • Knowledge of The Patient Bill of Rights
  • Demonstrates ability to effectively handle multiple tasks throughout the workday and to appropriately prioritize tasks
  • Demonstrate effective problem-solving techniques by resolving complaints and implementing effective solutions
  • Adhere to all Health System policies, procedures, guidelines and Standards of Behavior
  • Work cooperatively with all team members to achieve departmental, and
  • organizational goals  
  • Adheres to privacy and confidentiality rules in accordance with the Health System, State, Federal and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations
  • Perform other work as required or requested
  • Adhere to all Health System policies, procedures, guidelines and Standards of Behavior
  • Attend and participate in staff meetings, performance improvement, workshops/seminars to enhance skills and performance effectiveness
  • Ability to handle multiple tasks simultaneously and set appropriate priorities
  • Maintain a neat, clean, and orderly work area
  • Complete Self-Evaluation for annual performance evaluation
  • Perform other work as required or requested

  
Compensation

  • Commensurate with Experience

 
Additional Information

  • Full Time, M-F
  • Direct Placement; Benefited; Non-Exempt


Apply

Your Details

Please fill in the form below to send us brief details about you. We will use this information to get in touch to process your application in full.

Basic Details

First Name*

Last Name*

Contact Information

Email Address*

Phone Number

Mobile Phone Number

Supporting Comments

Please provide a short summary in support of your application for this vacancy.

Message

Attach Resume

Please attach a copy of your CV (.doc, .docx, .pdf)