Utilization Management RN Wanted!

HealthCare Talent; Camarillo (CA); On-site; USD 80,000 - 100,000; Full time

Job summary

HealthCare Talent is seeking a compassionate and detail-oriented Utilization Management Registered Nurse in Camarillo. This role involves reviewing requests for medical services, applying clinical guidelines, and ensuring quality care for patients.

The ideal candidate will have a registered nursing degree, with experience in case management or utilization review. Strong communication and organizational skills are essential for success in this position.

Qualifications

• Registered nursing degree with experience in case management or utilization review.
• Ability to apply principles of utilization management effectively.
• Strong communication and organizational skills.

Responsibilities

• Review medical service requests against guidelines.
• Promote cost-effective medical outcomes.
• Coordinate with clinical staff for timely care.
• Maintain accurate intervention records.

Skills

Utilization Management principles

Acute care nursing practices

Clinical guidelines application

Problem-solving skills

Conflict management

Organizational skills

Microsoft Office proficiency

Regulatory compliance knowledge

Communication skills

Typing skills

Education

Registered Nursing degree (preferably baccalaureate)

Job description

Are you a compassionate, detailed RN? We want the best Utilization Management Registered Nurse for our clients in Camarillo!

Under the direction of the Manager, UM, this position will review requests for medical services against National Clinical Guidelines. The UM Nurse uses judgment in selecting appropriate guidelines and in applying general policies and procedures. Responsible for screening enrollees for initiatives and programs including Case Management and Disease Management.

Job Description

• Review precertification requests for medical necessity.
• Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.
• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
  • promote improved quality of care and/or life
  • promote cost effective medical outcomes
  • prevent hospitalization when possible and appropriate
  • promote decreased lengths of hospital stays when appropriate
  • prevent complications in patients under our care when possible
  • provide for continuity of care
  • assure appropriate levels of care are received by patients
• Provide appropriate referrals to Case Management.
• Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
• Maintain accurate records of all interventions.
• Gather all pertinent information from providers and facilities to ensure physician reviewers have sufficient information to make a decision to approve or deny services.
• Coordinate with non‑clinical staff to ensure all documentation is completed timely and in a professional manner.
• Interface with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider.

Qualifications

Skills/Knowledge/Abilities

• The principles and practices of utilization management.
• Effectively apply acute care medical/surgical nursing practices.
• Use clinical guidelines for medical necessity determinations.
• Demonstrated ability to problem‑solve complex, multifaceted, emotionally charged situations.
• Ability to successfully manage conflict, negotiating "win‑win" solutions.
• Strong organizational, task prioritization and delegation skills.
• Computer literacy on Microsoft Office products.
• Knowledge of required regulatory timelines to ensure department compliance with State contracts.
• Knowledge of basic computer applications with ability to adapt to new software programs.
• Excellent communication and people skills.
• Excellent typing skills.

Education and Experience

All candidates must have a registered nursing degree, preferably at the baccalaureate level, as well as some experience in the field of case management and/or utilization review.