Utilization Management (UM), RN or LVN

Location: Orange, CA
Date Posted: 10-02-2017
Job Summary
The Utilization Management Prior Auth Nurse, under the direction of the Healthcare Services Director or HCS Manager/Supervisor is responsible for the day-to-day utilization management of outpatient cases, while promoting quality patient care outcomes through appropriate utilization/resource management. This position may also be involved with inpatient case management reviews as requested.
Essential duties and responsibilities include, but are not limited to:
  • Conducts ongoing reviews of outpatient referrals for non-delegated groups and delegated groups where the financial responsibility is the plan. Also reviews authorization requests for Out of Area Non-contracted facilities (in coordination with the Delegated IPAs).
  • Reviews/Approves outpatient referrals and presents cases as needed that do not meet criteria for review and decision by the Medical Director.
  • Notifies the appropriate individuals when members meet stop-loss criteria or there may be a third party liability according to department policy and procedure
  • Conducts utilization review for members receiving home health services for non-delegated groups.
  • Tracks continuity of care issues identified through the enrollment process, and resolves when identified as appropriate.
  • Ensures compliance with Medicare turnaround time and all applicable Federal, State and local laws, rules and regulations.
  • Ensures that authorizations are reviewed and screened for eligibility, out of area or out of network and based upon the Division of Financial Responsibility (DOFR).
  • Ensures compliance with the NOMNC process when SNF, HHA, or CORF services are terminated by coordinating with the IPA/MG and/or facility.
  • Appropriately drafts denial letters and authorized services and mails them out timely to member(s) and requesting provider(s).
  • Ensures that accurate and proper documentation and codes are noted/entered in the case management system.
  • Maintains case management records according to policy.
  • Interfaces with primary care physicians, specialty care physicians, mental health professionals, home health professionals and other health care professionals regarding patient care as needed.
  • Maintains confidentiality of information between and among health care professionals.
  • Assists with the review and development of new protocols, procedures and guidelines.
  • Recognizes work-related problems and contributes to solutions.
  • Maintains confidentiality of information between and among health care professionals.
  • Other duties as requested or assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Education and/or Experience : Successful completion of an accredited Licensed Vocational Nurse or Registered Nursing Program; one year recent UM or managed care experience or in a related field.
  • Certificates, Licenses, Registrations : Current, Active and Unrestricted Licensed Vocational Nurse or Registered Nursing License
  • Other Qualifications :
  • Knowledge of Medicare Managed Care Plans
  • Computer Skills: Word, Excel, Microsoft Outlook
  • Experience with the application of UM Criteria (i.e., Milliman Care Guidelines, Apollo, CMS National and Local Coverage Determinations, etc.)
  • Experienced in handling a full caseload of both inpatient and outpatient cases on a daily basis.
Skills and Abilities
  • Language Skills : Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
  • Mathematical Skills : Ability to perform mathematical calculations and calculate simple statistics correctly
  • Reasoning Skills : Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution;
  • Problem-Solving Skills : Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
  • Report Analysis Skills : Comprehend and analyze statistical reports.
  • Familiar with evidence based guidelines e .g. Milliman Care, Interqual, Apollo guidelines.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
  • The employee is frequently required to reach with hands and arms.
  • The employee is occasionally required to climb or balance and stoop, or kneel.
  • The employee must occasionally lift and/or move up to 20 pounds.
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Job Type: Full-time
Salary: $36.00 to $45.00 /hour
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