What are the responsibilities and job description for the Utilization Management Nurse Specialist RN II position at Working Nurse?
RN Job
Utilization Management Nurse Specialist RN II
Shift
Full Time
Pay Range
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Job ID
12988
Location
Los Angeles, 90017
Apply at Website
Email Recruiter
Job Description
The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves 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, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting.
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction 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. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.
Qualifications
Education Required:
As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.
Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.
Utilization Management Nurse Specialist RN II
Shift
Full Time
Pay Range
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Job ID
12988
Location
Los Angeles, 90017
Apply at Website
Email Recruiter
Job Description
The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves 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, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting.
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction 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. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.
Qualifications
Education Required:
- Associate's Degree in Nursing
- Education Preferred
- Bachelor's Degree in Nursing
- Experience Required:
- At least 5 years of varied RN clinical experience in an acute hospital setting.
- At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting .
- Managed Care experience performing UM and CM at a medical group or management services organization.
- Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
- Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System.
- Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
- Prepare clear, comprehensive written and oral reports and materials.
- Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team
- Excellent time management and priority-setting skills.
- Maintains strict member confidentiality and complies with all HIPAA requirements.Strong verbal and written communication skills. Preferred:
- Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM).
- Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid.
As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.
Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.
Salary : $88,854