Utilization Review Nurse
Top national managed care organization looking for Utilization Review Nurses (RN or LPN/LVN) in La Palma, CA! Great opportunity, please call us today!
Collect case specific member information, review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services. Review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care of delivery, and the need for planning subsequent care for contracted members and their eligible dependents as assigned. Providing clinical and managed care expertise, as well as Medical Director/physician consultation. Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Prospective Review Urgent/ Non-urgent, Concurrent Review, Retrospective Review, Early initiation of discharge coordination, Analyze case-specific patient information. Verify eligibility, as applicable, and past utilization history. Client-specific protocol and procedures Maximize referrals to network providers. Evaluation for referral to case management. Focused Second Surgical Opinion Review. Identifying and reporting quality of care issues. Answer telephone calls promptly as scheduled and as needed. Maintain working knowledge of all client groups Demonstrate adequate competence in computer software use in daily activities. Review case-specific patient information concurrently for the medical necessity of hospital admissions using commercial review criteria and/or scripted guidelines. Based on severity or complexity of the enrollees condition, ability to meet commercial review criteria and or scripted guidelines, the necessary treatment, and the discharge planning activity (not routinely conducted on a daily basis), the nurse reviewer will assign the appropriate LOS days/ visits/ services in review of the clinical information obtained. Document pertinent clinical information regarding individual reviews in SOAP format. Ensure timely notification of all parties (telephonic and/or written), as necessary, regarding certification recommendations. Assist in administering the second surgical opinion process. Handle caller requests addressed to other staff members; acts as a liaison assist the caller by routing to the appropriate person/ staff. Prepare case files for physician review via Physician Consultant Services or Medical director. This includes preparation of clinical information; correspondence. Function as a member of a self-directed team to meet specific individual and team performance metrics. Telephonic discussions with health care providers and members to explain medical necessity determinations and to obtain additional clinical information. Ensure consistent application of the utilization review process for all functional components. Document case review findings, actions, and outcomes in accordance with policy. Participate in special projects, as needed Participate in team meetings. Review clinical coverage reviews and assure client recommendations, as designated. Manage workload to ensure timely processing per state and federal mandates Other duties as assigned.
Active LPN nurse licensure; minimum of 1 year clinical experience in an acute care setting
Previous Utilization Management experience preferred
Sound clinical judgment, Demonstrated understanding of managed care concepts, Strong problem solving and decision making skills
Strong time management and prioritization skills, Excellent customer service skills including a sense of urgency and ownership for resolving issues
Strong interpersonal skills at an individual and team level, Ability to be flexible, adjust quickly and react positively to change, Knowledge of ICD-9 and CP coding preferred.
Shift: M-F 8 hour day shift
Location: La Palma, CA
This diversified healthcare company offers core capabilities in clinical care resources, information, and technology through it's healthcare coverage and benefits services and technology-enabled health services. The company services more than 80 million people and operates in all 50 states, earning it the designation as one of the "World's Most Admired Companies" in the insurance and managed care category by Fortune Magazine.
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
Qualified applicants in San Francisco with criminal histories will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.