Utilization Management Nurse Specialist – RN II

Santa Barbara Cottage Hospital; United States; Remote; USD 89,000 - 142,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan seeks an experienced Utilization Management Nurse Specialist RN II to facilitate and approve referrals, ensuring timely decisions in line with criteria. You will coordinate with hospital staff and physicians to optimize patient discharge planning and care transitions.

Role requires RN with 5+ years in acute care and 2+ years in UM/CM, plus strong communication and HIPAA compliance. On-site involvement in California with potential weekend/holiday needs and a broad benefits

Qualifications

• RN with at least 5 years of varied acute hospital nursing experience.
• At least 2 years in Utilization Management or Case Management in a hospital or HMO setting.
• Managed Care experience in UM/CM preferred (medical group or MSO).
• Experience with Medi-Cal, Medicare, and commercial lines.

Responsibilities

• Facilitate, coordinate and approve medically necessary referrals based on criteria.
• Generate and communicate referral determinations to members and providers.
• Monitor admissions in inpatient settings and conduct concurrent reviews.
• Collaborate with staff, physicians and providers to develop effective discharge plans.
• Manage data transfers and documentation in the system of record.
• Respond to provider inquiries with timely, accurate resolutions.

Skills

Excellent communication skills

Customer service

Time management

HIPAA compliance

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Outlook

Word

Excel

PowerPoint

L.A. Care Information System

Job description

L.A. Care Health Plan seeks an experienced Utilization Management Nurse Specialist RN II to facilitate and approve referrals, ensuring timely decisions in line with criteria. You will coordinate with hospital staff and physicians to optimize patient discharge planning and care transitions.

Role requires RN with 5+ years in acute care and 2+ years in UM/CM, plus strong communication and HIPAA compliance. On-site involvement in California with potential weekend/holiday needs and a broad benefits