Utilization Management Nurse Specialist RN II

About the role

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria.

Responsibilities

• 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.

Qualifications

Education

• Required: Associate's Degree in Nursing
• Education 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.

About The Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?

• Opportunity.
• Amazing co-workers.
• A supportive management team.
• Great compensation and benefits.
• Camaraderie and a true sense of mission.
• If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.