Utilization Management Nurse – RN, Case & Appeals

Anacalifornia; San Bernardino (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

Loma Linda University Health is seeking a Utilization Management Nurse to coordinate pre-authorization, concurrent review, and retro reviews for Health Plan members. The role includes negotiating rates, establishing policies, and serving as a clinical advisor for Level 1 appeal committees.

Required is an Associate's Degree in Nursing with two years of acute care hospital experience; a Bachelor's in Nursing is preferred. Active RN license in California is essential.

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 and retro review for Health Plan members.
• Negotiate discounted rates for single case agreements with non-preferred providers on urgent, emergent and concurrent cases.
• Negotiate pricing and contract terms with contracted providers.
• Establish policies, procedures and protocols for inpatient/outpatient procedures, tests, and DME.
• Serve as clinical advisor for Health Plan Level 1 Appeal Committees.
• Perform other duties as needed.

Skills

Utilization Review

Case Management

Data Analysis

Communication

English Proficiency

Leadership

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Access

Job description

Loma Linda University Health is seeking a Utilization Management Nurse to coordinate pre-authorization, concurrent review, and retro reviews for Health Plan members. The role includes negotiating rates, establishing policies, and serving as a clinical advisor for Level 1 appeal committees.

Required is an Associate's Degree in Nursing with two years of acute care hospital experience; a Bachelor's in Nursing is preferred. Active RN license in California is essential.