Impactful Utilization Management Nurse - Preauth & Review

California Nursing Students Association Incorporated; San Bernardino (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Loma Linda University Health is seeking an Utilization Management Nurse to coordinate pre-authorization, concurrent and retrospective reviews and manage utilization processes for Health Plan members. The role includes negotiating rates for urgent cases and contributing as a clinical advisor on appeal committees.

Education requirements include an RN license with associate level as minimum and a bachelor’s degree preferred; two years of acute care hospital experience is required, with UR/UM

Qualifications

• Associate's Degree in Nursing required.
• Bachelor's Degree in Nursing preferred.
• Minimum two years of Acute Care Hospital experience required.
• Hospital utilization review or case management experience preferred.

Responsibilities

• Coordinate pre-authorization, concurrent review, and utilization management processes.
• Negotiate discounted rates for single case agreements with providers.
• Develop policies and protocols for inpatient/outpatient care and DME.
• Serve as clinical advisor for Health Plan Level 1 Appeal Committees.

Skills

Utilization Review

Case Management

Data Analysis

Communication

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing

Tools

Word

Excel

PowerPoint

Access

Job description

Loma Linda University Health is seeking an Utilization Management Nurse to coordinate pre-authorization, concurrent and retrospective reviews and manage utilization processes for Health Plan members. The role includes negotiating rates for urgent cases and contributing as a clinical advisor on appeal committees.

Education requirements include an RN license with associate level as minimum and a bachelor’s degree preferred; two years of acute care hospital experience is required, with UR/UM