Utilization Management RN: Care Pathways & Appeals

Loma Linda University Health; San Bernardino (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Loma Linda University Health is seeking a Utilization Management Nurse to coordinate pre-authorization, concurrent review, retro clinical review and utilization management processes for Health Plan members in our hospital system.

The role includes negotiating discounted rates for single case agreements with urgent and non-preferred providers, working with contracted providers on pricing and contract terms, and developing policies for inpatient, outpatient procedures and DME.

Qualifications

• Associate degree in nursing required; bachelor's preferred.
• Minimum two years of acute care hospital experience.
• Hospital utilization review or case management experience preferred.

Responsibilities

• Coordinate pre-authorization, concurrent review, retro clinical review and UM processes for Health Plan members.
• Negotiate discounted rates for single case agreements with urgent, emergent, and concurrent cases.
• Negotiate with contracted providers for pricing and contract terms.
• Establish policies, procedures and protocols for inpatient, outpatient procedures, tests, DME, etc.
• Participate as clinical advisor for Health Plan Level 1 Appeal Committees.
• Perform other duties as needed.

Skills

Utilization Review (UR)

Case Management (CM)

Data analysis

Microsoft Office Suite

Communication skills

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Word

Excel

PowerPoint

Access

Job description

Loma Linda University Health is seeking a Utilization Management Nurse to coordinate pre-authorization, concurrent review, retro clinical review and utilization management processes for Health Plan members in our hospital system.

The role includes negotiating discounted rates for single case agreements with urgent and non-preferred providers, working with contracted providers on pricing and contract terms, and developing policies for inpatient, outpatient procedures and DME.