UM Registered Nurse

Under direction of the Medical Director and Director of Utilization Management, the Utilization Management Nurse, RN, is responsible for clinical review for members receiving care in an inpatient setting. This role will review the appropriateness and medical necessity of admissions and continuing inpatient confinement utilizing clinical guidelines and Medicaid criteria as well as make first level approval determinations and appropriately refer cases to the Medical Director for second review when case does not meet criteria. Incumbents in this position are competent in all essential areas of utilization management. Utilization Management Nurses work independently under general direction, nurses at this level may need support and guidance in more complicated case reviews or discharge plans. This position involves frequent communication with members, caregivers, medical providers, and staff telephonically, electronically, and potentially in-person. UM Nurses may be assigned at on-site facilities or may work at company offices. 

Duties include

• Conducting clinical inpatient reviews – prospective, concurrent, and retrospectively
• Working in collaboration with hospital staff and other network providers for efficient and timely discharge planning
• Initiating discharge planning activities starting at admission
• Working closely with facility discharge planners and case managers
• Referring cases to Case Management and Disease Management programs when clinically indicated
• Ensuring that all clinical documentation is timely and up-to-date so that the daily census report is reliable and accurate including timely documentation of all discharges
• Referring cases to the Social Worker for social interventions when indicated
• Communicating, consulting, and collaborating with Medical Director on an as needed basis
• Serving as a liaison to community providers and Members
• Acting as a preceptor to new staff; Making first level approval determinations when request meets medical necessity and benefit criteria within required turnaround times
• Identifying and referring cases for quality of care, coordination of benefits, and third-party liability issues as appropriate
• Benefits interpretation to include coordination of care for medically necessary services that are not covered under the Plan (e.g. CCS, Mental Health, Long Term Care, State Waiver Programs)
• Presenting cases and rationale to Medical Director for potential denial determinations
• Ensuring that case notes are timely, concise, and indicate exactly why the patient is meeting inpatient level of care criteria on a daily basis
• Documenting such on a concurrent basis
• Performing retrospective reviews within 3 business days of notification of admission (weekend admissions, etc.)
• Maintaining and updating authorizations in Core Claims Adjudication system to enable timely payment of claims
• Performing at 85% or higher on inter-rater reliability audits
• Coordinating services with other key departments (i.e. Member Services, Provider Relations)
• Performing other duties as assigned

Knowledge and Skills Requirements

• Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution
• Adheres to Code of Ethics and Business Conduct and all company policies (e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor)
• Represent company in a positive manner to all members, caregivers, staff, and external stakeholders
• Demonstrate commitment to continuous improvement
• Strong knowledge of acute chronic care nursing principles, methods, and common treatments
• Strong knowledge of common human diseases and usual and customary methods of treatments
• Demonstrated knowledge of medical terminology
• Knowledge of acute hospital organization and interrelationships of various clinical and diagnostic services
• Ability to assess and judge the clinical performance of physicians and other health professionals
• Knowledge of ICD10 and/or CPT coding
• Ability to effectively evaluate medical records to determine appropriateness and necessity of care
• Demonstrated knowledge of health care delivery systems
• Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of the company
• Ability to use tact and diplomacy to diffuse emotional situations
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards
• Basic skills in Microsoft Word and Excel with basic ability to enter data into and navigate through a database
• Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, company business, or employee information and make no disclosure of such information except as required in the conduct of business
• Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork
• Self-directed, with proven ability to work independently with minimum supervision
• Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis
• Strong attention to detail and ability to work accurately and at a reasonable rate of speed
• Compliant with company policies and procedures and performs the job safely and with respect to others, to property, and to individual safety
• Demonstrated knowledge of regulations and requirements related to utilization management (UM)
• Experience with QA/QI and program development/process improvement
• Multi-task in an interrupt-driven environment and complete projects on a timely basis
• Strong analytical and problem-solving skills
• Demonstrates ability to respect and maintain the confidentiality of all sensitive documents, records, discussions, and other information generated in connection with activities
• Maintain effective working relationships, present oneself professionally
• Applicants should be able to demonstrate knowledge and experience of managed care systems
• Demonstrated skills in coordination and problem solving, planning and coordinating the work with others
• Work well and communicate with people of various professional backgrounds
• Able to utilize reporting tools, reporting analysis, and Microsoft Office Suite

Education and Experience

• Registered Nurse with an active, current, unrestricted license
• Associate’s Degree in Nursing required
• Bachelor’s Degree from an accredited school or equivalent in Nursing, Health Administration, or related healthcare field preferred
• Minimum of 2 years full-time clinical experience in acute care, community health setting, public health nursing, or chronic disease management required
• Experience working with patients and caregivers regarding self-care and disease management required
• Experience working in case management or care coordination is a plus
• Experience with MCG Clinical guidelines, Medi-cal, and California Children’s Services preferred
• Knowledge of community resources for seniors and people with disabilities is a plus

Working Conditions

Environment 

While performing duties of job, employee is required to move about the organization for roughly 10% of the day. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods for up to and sometimes beyond 50% of the day. 

Physical Demands

Overall, employee must be able to perform all these demands in a fast-paced and constantly changing environment which may require multiple demands to be performed at once. 1st shift, On-Site. Temp-to-Hire position. Wage: $47.00 hr. (#6.1013.109 – Bakersfield)