Job Description

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.

Preferred:

• 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.Skills Required: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.

Licenses/Certifications Required:

• Registered Nurse (RN) - Active, current and unrestricted California License

Licenses/Certifications Preferred:

• Certified Case Manager (CCM)

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