Utilization Management Nurse (Inpatient and Outpatient)
The Utilization Management Nurse role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing patient treatment files, the Utilization Management Nurse will ensure that patients won’t receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.
*Multiple positions available
Job Duties
Review clinical information for medical necessity determinations of provider service requests for the inpatient and outpatient services.
Perform initial and ongoing reviews for inpatient admissions, level of care, observation, pre-service, concurrent review and discharge planning in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements.
Process requests for prior authorization of outpatient services in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements.
Conduct all medical necessity clinical reviews in Customer’s care management platform for full transparency and tracking of Nurse activities and performance measures.
Participate in department meetings, training, and audit activities equal to Customer employees.
Role/Education Requirements
Active California RN License
Minimum of 2 years of recent health plan experience
High level of expertise in UM services
Experience with MediCal and LA Country procedures and policies (preferred but not required)
Experience with MCG Criteria (preferred but not required)
Role Details
Job Type: Contract
Standard PST business hours, Monday through Friday
Evenings, weekends or holiday coverage, as needed
Work Location: Remote