Nurse Case Manager
The Utilization Review Nurse provides a variety of services with respect to medical care authorization and delivery, cost containment, claims review, appeals and grievances, and analytical reporting. As part of our Medical Management Team, the NC employs best practices and principles to ensure high quality and cost-effective assurance standards.
- Act as a liaison between Medical Case Manager and Medical Management
- Coordinators regarding medical review issues.
- Authorize medical services by using medical policy guidelines of the department to process sensitive and confidential information; refer the request to an RN Medical Case Manager or a Physician Reviewer as appropriate.
- Conducts pre-certification, concurrent, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the member??s eligibility, benefits and contract.
- Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
- Communicate with other departments and personnel to facilitate adjudication of claims.
- Communication with hospitals, physicians, and subscribers regarding certification of hospital admissions, outpatient services and post procedure follow up.
- Maintains communication between insured, medical provider, and insurance company.
Working hours: 8:00 AM - 5:00 PM
- Knowledge and application of state and federal laws, statutes, and regulations; excellent analytical skills.
- Knowledge of principles, practices and current trends in nursing as well as best practices in quality assurance.
- Knowledge and ability to utilize evidence based medical guidelines.
- Patient care evaluation skills.
- Working knowledge of ICD-10, HCPCS and CPT coding.
- Durable Medical Equipment knowledge preferred.
- Working knowledge of medical terminology.
- Ability to work independently and within a team environment, including ability to coordinate a team for effective results.
- Minimum of at least two years clinical experience with at least one year of case management or utilization review experience; or equivalent and any combination of education, training, and/or experience, which demonstrates ability to perform the duties described.
- Current California RN/LVN License.
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