Utilization Management Nurse, LVN/LPN

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient centered care across the care continuum.

Responsibilities

Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members; Review cases for medical necessity and apply the appropriate clinical criteria, including but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines; Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations; Ensure discharge planning is timely and appropriately communicated to transition of care teams, when applicable; Meet or exceed productivity targets set forth; Serve as a resource to non-clinical team members when applicable; Adhere to the Policies and Procedures set forth by the Quality Management Committee and perform all additional duties as assigned.

Requirements

Minimum 2 years of experience in medical management clinical functions; Working knowledge of MCG, InterQual, and NCQA standards; Active and Unrestricted License as a Licensed Vocational Nurse (LVN) for California

Nice to have

Associate’s degree in Nursing; Certification Managed Care Nursing (CMCN)

Benefits

health benefits; life and disability benefits; 401(k) savings plan with match; Paid Time Off; paid holidays