Utilization Management Nurse Specialist RN II

Working Nurse; Los Angeles (CA); On-site; USD 89,000 - 142,000; Full time

Job summary

Working Nurse in Los Angeles, CA is seeking a Utilization Management Nurse Specialist RN II. This full-time position focuses on facilitating, coordinating, and approving medically necessary referrals, with timely determination and clear communications to members and providers.

You will monitor admissions, perform reviews, gather medical records, and work with the UM Manager and Physician Advisor on case reviews across pre-service to retrospective claims.

Qualifications

• Associate's Degree in Nursing required.
• Bachelor's Degree in Nursing preferred.
• At least 5 years RN clinical experience in an acute hospital setting.
• At least 2 years of Utilization Management/Case Management experience.

Responsibilities

• Facilitates, coordinates, and approves medically necessary referrals.
• Monitors admissions and performs reviews for discharge planning.
• Collaborates with UM Manager and Physician Advisor on case reviews.
• Handles provider inquiries and communicates decisions clearly.

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

RN Job

Utilization Management Nurse Specialist RN II

Shift

Full Time

Pay Range

$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

Job ID

13270

Location

Los Angeles, 90017

Job Description

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination.

Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan.

Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes.

Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.

Qualifications

Education Required

• Associate's Degree in Nursing

Education

• Bachelor's Degree in Nursing

Experience Required

• At least 5 years of varied RN clinical experience in an acute hospital setting.
• At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.

Preferred

• Managed Care experience performing UM and CM at a medical group or management services organization.
• Experience with Managed Medi-Cal, Medicare, and commercial lines of business.

About The Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us

• Opportunity
• Amazing co-workers
• A supportive management team
• Great compensation and benefits
• Camaraderie and a true sense of mission
• If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.