Utilization Mgmt Nurse

California Nursing Students Association Incorporated; San Bernardino (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Loma Linda University Health is seeking an Utilization Management Nurse to coordinate pre-authorization, concurrent and retrospective reviews and manage utilization processes for Health Plan members. The role includes negotiating rates for urgent cases and contributing as a clinical advisor on appeal committees.

Education requirements include an RN license with associate level as minimum and a bachelor’s degree preferred; two years of acute care hospital experience is required, with UR/UM

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 review, and utilization management processes.
• Negotiate discounted rates for single case agreements with providers.
• Develop policies and protocols for inpatient/outpatient care and DME.
• Serve as clinical advisor for Health Plan Level 1 Appeal Committees.

Skills

Utilization Review

Case Management

Data Analysis

Communication

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing

Tools

Word

Excel

PowerPoint

Access

Job description

JOB DESCRIPTION

Shared Services: Risk Management- (Full-Time, Day Shift) -

Job Summary:

The Utilization Management Nurse is responsible for coordinating the pre-authorization, concurrent review, retro clinical review and utilization management process of the Health Plan members. Negotiates discounted rates for single case agreements for non-preferred providers on urgent, emergent and concurrent cases. Negotiates with contracted providers for pricing and contract terms. Establishes policies, procedures and protocols through research, development, implementation and monitoring of criteria for inpatient, outpatient procedures, tests, durable medical equipment (DME), etc. For Health Plan benefit determination. Participates as clinical advisor for Health Plan Level 1 Appeal Committees. Performs other duties as needed.

Education and Experience:

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.

Knowledge and Skills:

Appropriate levels of care, Utilization Review (UR), Utilization Management (UM), Case Management (CM), claims familiarity, clinical pathways, billing and coding regulations. Ability to analyze and interpret data; judge and act on analysis of data; apply mathematics to manipulate/analyze data; analyze and solve specific problems; Able to read; write and speak with professional quality; use computer and software programs necessary to the position, e.g., Word, Excel, Power Point, Access; operate/troubleshoot basic office equipment required for the position. Able to relate and communicate positively, effectively, and professionally with others; provide leadership; be assertive and consistent in enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently; perform basic math and statistical functions; manage multiple assignments; compose written material; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.

Licensures and Certifications:

Active California Registered Nurse (RN) license required. Certified Professional in Healthcare Management (CPHM), Certified Professional Utilization Review (CPUR) or Certified Professional Utilization Management (CPUM) preferred.

ABOUT US

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.

ABOUT THE TEAM

Loma Linda University Health is a Seventh-day Adventist, faith and values based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities.

We are an equal opportunity employer committed to the principles of diversity.

We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law.

In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability.

If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at [phone].

Loma Linda University Shared Services is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964.

No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant's consideration for employment because of race, color, religion, gender, age, national origin, disability, genetic information, or any other status protected by applicable law.

If you need a reasonable accommodation in the hiring process, please notify Human Resource Management.

We appreciate your interest in Loma Linda and wish you success in your job search!