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Utilization Review Nurse

Company: MEDsearch (CA)
Location: Pasadena
Posted on: January 11, 2019

Job Description:

CLIENT COMPANY OVERVIEW.
Our client is an innovative network of providers delivering innovative and quality care to patients from Northern to Southern California. JOB TITLE
UM Review Nurse - RN
JOB SUMMARY
The Utilization Nurse is responsible to assure health care services are available to medical group members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.
JOB DUTIES

  • Provides first level clinical review for all outpatient, planned inpatient and ancillary services requiring authorization. Performs retrospective chart review as indicated.
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
  • Refers those requests that do not meet medical criteria review to the Medical Director or Physician Advisor for second level review and determination.
  • Completes data entry and correspondence as necessary for each review.
  • Answers Utilization Management directed telephone calls; managing them in a professional and competent manner.
  • Processes all prior authorizations to completion utilizing appropriate review criteria.
  • Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity.
  • Acts as liaison between the IHHMG members, network providers Provider Relations Department for contracted health plans.
  • Screens and refers appropriate health plan members for short term or complex case management, disease management, or other care management strategies as applicable.
  • Maintains knowledge of and is compliant with current UM Plan and policies & procedures.
  • Performs quality improvement activities and maintains current quality improvement document as directed.
  • Perform other duties as assigned. QUALIFICATIONS
    • Current California RN License
    • 3+ years of nursing experience in an acute care hospital setting
    • 3+ years of managed care and utilization review experience
    • Experience with clinical review
    • Spanish speaking or other second language a plus! POSITION CLASSIFICATION & COMPENSATION Full-Time/Contract to Hire
      • $39 - $40.50hr

        Keywords: MEDsearch (CA), Pasadena , Utilization Review Nurse, Healthcare , Pasadena, California

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