The Utilization Management Nurse (per diem) will perform telephonic medical necessity reviews utilizing established and evidenced based criteria on all designated pre-certification requests, as well as targeted outpatient procedures, services and inpatient admissions.
Essential Functions:
- Review of outpatient and inpatient admissions and/or services; concurrent review and discharge planning for all member's admitted to acute, sub-acute and/or skilled nursing facilities; retrospective review for services not pre-certified and/or reconsiderations. In collaboration with physician and healthcare team, facilitate appropriate resource utilization within contracted and non-contracted facilities.
- Evaluate eligibility and benefit information and educates member and/or family, physician and interdisciplinary healthcare team as to meet the health needs of the member and minimize out of pocket costs.
- Identify and refer appropriate members to case management, disease management, risk management and quality improvement.
- Establish relationships and communicate with members, family, inpatient and outpatient providers and case managers, community resources, skilled nursing staff, member's service, claims, contracts, benefits, appeals, risk and quality management.
Qualifications:
Basic Qualifications:
- BSN degree
- CA RN license
- Certificate in Utilization Management or within one year of hire.
- Minimum of 3 years recent Utilization Management experience in a PPO environment
- Ability to interpret financial data, calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
- Experience with URAC and/or NCQA accreditation process.
- Excellent verbal and written communication skills.
- Strong customer service orientation, with demonstrated ability to understand and meet customer needs.
- Proficient in multiple computer applications including Microsoft Office
- This position is 40 hours a week Monday through Friday (11am - 7pm or 12pm - 8pm), possible weekends in the future.
- Possible telecommuting opportunity in the future.
Preferred Qualifications:
- MSN
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.