Job req ID: 6858
The Utilization Management Nurse Specialist RN II will facilitate, coordinate and approve of 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, modifications and denials communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes.
Provides the primary clinical point of contact for the Community Access Network FRC in their assigned community. Ensures that L.A. Care CAN Utilization Management goals met, and in a manner consistent with enhancing positive business growth. Functions as the clinical SME for all MSO-level activities.
Performs prospective, concurrent, post-service and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies cases needing Physician Advisor (PA) review or input. Presents cases to PA for potential review or determinations when needed.
Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.
Identifies and initiates referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director.
Perform other duties as assigned.
CA RN License
At least 5-7 years of varied clinical experience in an acute hospital setting. At least 2 years Utilization Management experience in a hospital or HMO setting. At least 2 years CM experience in a home health, hospice, or HMO setting.
Managed Care experience performing UM and CM at a Participating Physical Group (PPG) or MSO.
Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
Experience with special needs populations.
Additional years of preferred experience could be substituted for missing required years of experience.
What are the 3-4 non-negotiable requirements of this position?
California RN license Associate’s degree in Nursing At least 5 years of nursing exp and 2 years of UM nurse exp.
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