UM Nurse (California License)

RIT Solutions, Inc.; New York (NY); Remote; USD 70,000 - 90,000; Full time

Job summary

A remote opportunity for a UM Nurse is available with a leading healthcare solutions company. The role focuses on promoting quality outcomes through coordination and collaboration across care settings, reviewing case necessities, and ensuring resource fulfillment for member health needs. Candidates require prior experience in clinical functions and familiarity with clinical criteria guidelines, making this a crucial role in improving patient care quality.

Qualifications

• Minimum of 2 years experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards.

Responsibilities

• Perform medical necessity reviews for an assigned panel of members.
• Collaborate with Medical Director for quality standards.
• Ensure timely discharge planning communication.

Skills

Clinical criteria application

Medical necessity reviews

Collaboration

Education

Associate's degree in Nursing

Tools

MCG

InterQual

NCQA standards

Job description

Job Title : UM Nurse (California License) - Must be licensed in California - Remote Opportunity

Work Hours : 8am - 5pm PDT, with availability for evening, weekend, and holiday coverage

Openings : 5

Location : Remote

Ready to Hire : ASAP

Job Description

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 members receive the 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.

This position is not patient-facing; responsibilities include reviewing patient records and providing recommendations.

Role and Responsibilities

1. Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members.
2. Review cases for medical necessity and apply appropriate clinical criteria, including but not limited to Medicare, Medicaid/Medi-Cal, Interqual, Milliman, or health plan-specific guidelines.
3. Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on quality standards.
4. Ensure discharge planning is timely and appropriately communicated to transition of care teams, when applicable.
5. Meet or exceed productivity targets set forth.
6. Serve as a resource to non-clinical team members when applicable.

Qualifications and Education

• Associate's degree in Nursing preferred.
• Minimum of 2 years experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards.