Utilization Management Nurse Specialist RN II
for section headings. Use - for any list of duties/requirements/benefits. Use
for prose.
We need to decide what to list as lists.
Responsibilities: we have many duty sentences. Could be a list.
Requirements: maybe education and experience? Could be separate sections: Education, Experience? But we only have headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map content to these.
- About the role: company description, mission, job summary.
- Responsibilities: duties (list).
- Requirements: maybe education and experience? Could be combined.
- Qualifications: maybe licenses/certifications? Or could be skills? Actually typical: Requirements = education/experience; Qualifications = licenses/certifications; Skills = skills. We'll follow that.
- Skills: skills required.
- Benefits: benefits list.
- Pay: salary range.
- Schedule: additional info about weekends/holidays.
We must not invent sections; we must only include if posting has real specific content.
All sections have content.
Now we need to preserve all substantive information; do not invent or summarize away detail. So we need to include all details from the posting, but we can format as lists.
We must not repeat job title.
We must not include boilerplate like EEO etc. Not present.
Now produce HTML fragment.
Let's extract content precisely.
About the role:
- Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
- Job Summary: 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.
We'll combine into prose paragraphs.
Responsibilities (duties):
List from "Duties" and "Duties Continued". Let's extract each bullet-like sentence.
From Duties:
- Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.
- Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
- Process, finalize and facilitate inbound requests that are received from providers.
- Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
- Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs.
- Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business.
- Identification of potential areas of improvement within the provider network.
- Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH).
- Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy.
- High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director.
- Document in platform/system of record.
- Utilize designated software system to document reviews and/or notes.
- Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps.
- Follow up with caller to provide response or resolution steps.
- Answer all inquiries in a professional and courteous manner.
- Perform Other Duties As Assigned.
From Duties Continued (actually same as above? It repeats many). We need to avoid duplication. The text after "Duties Continued" repeats many of the same items. We should not duplicate. We'll just include unique duties.
Let's list unique duties from both sections (they are largely same). We'll combine.
Unique duties:
- Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.
- Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
- Process, finalize and facilitate inbound requests that are received from providers.
- Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
- Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs.
- Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business.
- Identification of potential areas of improvement within the provider network.
- Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH).
- Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy.
- High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director.
- Document in platform/system of record.
- Utilize designated software system to document reviews and/or notes.
- Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps.
- Follow up with caller to provide response or resolution steps.
- Answer all inquiries in a professional and courteous manner.
- Perform Other Duties As Assigned.
That seems comprehensive.
Now Requirements: Education and Experience.
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.
We'll put these as list items under Requirements.
Qualifications: Licenses/Certifications.
Required: Registered Nurse (RN) - Active, current and unrestricted California License
Preferred: Certified Case Manager (CCM)
Also maybe Required Training? Not given.
We'll list.
Skills: Skills Required and Preferred.
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. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills.
Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.
We'll list as bullet points.
Benefits: Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental and Vision, Wellness Program, Volunteer Time Off (VTO).
Pay: Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) -
for prose. We need to decide what to list as lists. Responsibilities: we have many duty sentences. Could be a list. Requirements: maybe education and experience? Could be separate sections: Education, Experience? But we only have headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map content to these. - About the role: company description, mission, job summary. - Responsibilities: duties (list). - Requirements: maybe education and experience? Could be combined. - Qualifications: maybe licenses/certifications? Or could be skills? Actually typical: Requirements = education/experience; Qualifications = licenses/certifications; Skills = skills. We'll follow that. - Skills: skills required. - Benefits: benefits list. - Pay: salary range. - Schedule: additional info about weekends/holidays. We must not invent sections; we must only include if posting has real specific content. All sections have content. Now we need to preserve all substantive information; do not invent or summarize away detail. So we need to include all details from the posting, but we can format as lists. We must not repeat job title. We must not include boilerplate like EEO etc. Not present. Now produce HTML fragment. Let's extract content precisely. About the role: - Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. - Job Summary: 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. We'll combine into prose paragraphs. Responsibilities (duties): List from "Duties" and "Duties Continued". Let's extract each bullet-like sentence. From Duties: - Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. - Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. - Process, finalize and facilitate inbound requests that are received from providers. - Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. - Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. - Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. - Identification of potential areas of improvement within the provider network. - Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). - Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. - High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. - Document in platform/system of record. - Utilize designated software system to document reviews and/or notes. - Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. - Follow up with caller to provide response or resolution steps. - Answer all inquiries in a professional and courteous manner. - Perform Other Duties As Assigned. From Duties Continued (actually same as above? It repeats many). We need to avoid duplication. The text after "Duties Continued" repeats many of the same items. We should not duplicate. We'll just include unique duties. Let's list unique duties from both sections (they are largely same). We'll combine. Unique duties: - Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. - Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. - Process, finalize and facilitate inbound requests that are received from providers. - Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. - Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. - Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. - Identification of potential areas of improvement within the provider network. - Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). - Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. - High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. - Document in platform/system of record. - Utilize designated software system to document reviews and/or notes. - Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. - Follow up with caller to provide response or resolution steps. - Answer all inquiries in a professional and courteous manner. - Perform Other Duties As Assigned. That seems comprehensive. Now Requirements: Education and Experience. 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. We'll put these as list items under Requirements. Qualifications: Licenses/Certifications. Required: Registered Nurse (RN) - Active, current and unrestricted California License Preferred: Certified Case Manager (CCM) Also maybe Required Training? Not given. We'll list. Skills: Skills Required and Preferred. 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. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. We'll list as bullet points. Benefits: Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental and Vision, Wellness Program, Volunteer Time Off (VTO). Pay: Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) -