Um Nurse, Rn - 4/10 Weekend Shift (Remote)

Position Summary/Position

Under the general direction of the Utilization Management Manager, the Utilization Management Nurse is responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. This position is responsible to ensure meeting Member’s needs using nationally recognized UM criteria.

Major Functions (Duties and Responsibilities)

1. Responsible for reviewing prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of service and care including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and any high dollar cases.
2. Responsible for the prospective and retrospective review of referral denials, denial letters, and logs to determine appropriateness of denial, possible alternative treatment, and evaluation for case management or quality of care issues in collaboration and direction of UM Medical Director.
3. Draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language.
4. Work closely with Medical Directors to ensure consistent use of guidelines/criteria.
5. Create and maintain a standardized matrix of denial language split by LOB for internal and external use.
6. Responsible for assisting with the letter of agreement process when referring Members to out-o-network providers.
7. Review and report quality review findings with UM Management in order to support requirements of accuracy and productivity on a monthly basis.
8. Screen medical information provided and authorization requests for medical necessity and appropriateness, comparing the information to current criteria and discussing with Medical Directors.
9. Support all of UM Team with benefit interpretation and understanding of UM policies and procedures.
10. Assist Medical Directors with benefit interpretation, obtaining additional medical necessity information and researching issues.
11. Assist Medical Directors with revisions to IEHP UM Subcommittee Guidelines to ensure appropriate interpretation of criteria.
12. Attend staff meetings and education trainings necessary to maintain current nursing and UM knowledge.
13. Participate actively in LEAN activates to support the goals of the Department.
14. Assist with the utilization management section of the Medical Management audit, as well as focused referral and denial audits.

Experience Qualifications

Two (2) or more years of utilization management experience in a health care delivery setting specifically in prior authorization or two (2) or more years of experience in an acute care facility.

Preferred Experience

Experience in an HMO or experience in a Managed Care setting preferred.

Education Qualifications

High school diploma or GED required.

Professional Certification

Professional Licenses

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Knowledge Requirement

Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements specifically as they relate to UM/Health Plan correspondence.

Abilities Requirement

Exhibits a high attention to detail in documenting UM referral reviews. Ability to work at a high level of speed while maintaining accuracy. Ability to work well with both physician and nursing staff.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.