UM Quality Improvement Nurse

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  • 19-00356
  • Direct Placement
  • Recruiting
  • Torrance, CA
Job Description
UM Quality Improvement Nurse
(IPA/Medical Group)
Under the direction of the Manager, Utilization Management, the UM Quality Improvement Nurse ensures that all UM functions are in compliance with health plan and regulatory standards.  The UMQIN will monitor internal UM processes and functions to ensure consistency of using correct evidence based clinical criteria, health plan specific guidelines, meeting turn-around time (TAT) requirements, accurate reflection of denial type, and the use of concise grade level appropriate denial language utilizing the most current health plan specific, approved denial templates under appropriate state and federal requirements..  The UMQIN will also assist with and coordinate various quality improvement projects/programs within the Medical Management Department
Primary Duties and Responsibilities:

  • Conduct internal UM audits on referral management processes, including but not limited to consistency of using correct evidence based clinical criteria, and health plan specific guidelines, meeting TAT, accurate reflection of denial type, using clear and concise grade level appropriate denial language and most updated denial templates from health plans within the requirements of both California state law and federal Centers for Medicare and Medical (CMS) requirements.
  • Analyze authorizations and denial letters in accordance with California Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards
  • Perform internal and external communications to obtain needed information and verification of data related to audits or report submissions to the health plans
  • Review and assist Physician Reviewers in composing denial reasons to ensure the denial reason language is clear and concise and citing correct clinical criteria and utilizes the correct product specific grade level language
  • Prepare summary reports of the audit findings to the leadership team to initiate and identify needed corrective action plans
  • Prepare and review health plan pre- audit documents and collaborate with Compliance Manager as well as UM Manager for pre-audit documents submission
  • Validate Medicare Organization Determinations, Appeal, and Grievances (ODAG) and Medicare Advantage Part C reports with Senior UM Nurse prior submission to health plans
  • Prepare participate in health plan audits, pre-audit documentation submissions and corrective action plans based on health plan audit findings with Compliance Manager as well as UM Manager
  • Identify opportunities for improvement in UM processes and collaborate with UM Manager to develop improvement plans and training programs
  • Conduct staff trainings related the UM delegated activities under the direction of UM Manager
  • Review and prepare case summaries for member grievances related to potential quality of care issues
  • Provide collaborative support for organization of quarterly CQI meetings
  • Provide collaborative support for organization of quarterly/Semiannual Workplans
  • Actively participates in Utilization Management Committee Meetings.
  • Perform other work as required or requested
  • Complete Self-Evaluation for annual performance evaluation

Interpersonal Relationships:

  • Maintain cordial and professional relationships with health plan contacts and team members.
  • Work closely with UM Manager and Compliance Manager in support of ensuring UM compliance
  • Conduct UM staff trainings related to UM delegated activities under the direction of UM Manager and Sr. Director of Medical Management
  • Collaborate with Ambulatory Care Management (ACM), Inpatient Care Management (ICM), Compliance, Provider Relations, Contracting and Member Services to foster open inter departmental communication.
  • Support  Health System's Values of Service, Excellence, Knowledge, Stability and Community and behaves in a manner that reflects these values
  • 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
  • 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
  • Maintain a neat, clean, and orderly work area


  • Current RN unrestricted CA license
  • Bachelor's degree in nursing or related field preferred
  • Thorough knowledge of Registered Nurse (RN) scope of practice, current state requirements
  • One to two years of UM auditing experience
  • One to two years of experience in utilization management, required
  • Knowledge and experience in Managed Health Care
  • Working knowledge of Medicare ODAG and Medicare Advantage Part C report requirements and scheduling
  • Knowledgeable of health plan requirements, DMHC, DHCS and CMS regulatory guidelines related to UM processes, including  product specific TAT, member and provider notification of outcomes of UM determinations,  grade level language requirements, and identification of current appropriate health plan letter templates
  • Experience with NCQA standards and review process
  • Knowledge of CMS Conditions of Participation
  • Knowledge of The Patient Bill of Rights
  • Skilled in MSWord, Excel, Electronic Health Records, Medicare and Milliman  guidelines
  • Strong analytical, organization and time management skills
  • Excellent verbal and written communication skills


  • Commensurate with Experience

 Additional Information

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


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