Utilization Mgmt Nurse

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

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.