My Specialty
Utilization Management Nursing, L.A. Care
Reviewing medical services or prior authorizations
L.B., RN
Utilization Management Nurse Specialist RN II
L.A. Care Health Plan Los Angeles
Can you briefly describe your nursing career journey?
I got my first nursing job in orthopedics, where I worked for more than seven years. Someone I knew told me about home health, so I started doing private-duty nursing on the side while working full time. Because I was IV-certified, there were all sorts of opportunities available.
Once I got married and had a baby, being on call 24/7 wasn’t practical any more. I got a job with a provider group working on prior authorizations, and found I loved it. It combined administration and leadership, giving me the opportunity to learn the business side of healthcare.
A friend of mine kept trying to recruit me to L.A. Care Health Plan. I eventually learned they offered telecommuting, which was exactly what I was looking for: I can work from home until I retire.
Tell us what you do as a utilization management specialist.
L.A. Care is a publicly operated health plan that serves about one-fourth of the residents of L.A. County. Our members are covered by different insurance plans, including Medi-Cal, Medicare, and a Covered California plan. In an HMO environment, certain services, like imaging, require prior authorization.
A provider or member submits a request, and utilization management (UM) reviews it to determine whether it’s considered medically necessary and whether it’s covered by the member’s plan.
How do you determine whether to approve a request?
First, we determine the member’s benefits, understanding that the services that are covered may vary depending on their insurance plan.
Some services, such as infertility treatment or cosmetic procedures, may be excluded based on the plan benefits. For services such as imaging studies, surgeries, or durable medical equipment, we then review the request to determine whether it meets the criteria for medical necessity.
If not, the request may be denied, although of course both the provider and the member have the right to appeal. We primarily follow the clinical criteria established by the member’s health plan, which are reviewed and updated on a regular basis.
In situations where established criteria aren’t available for a particular service, L.A. Care may develop our own clinical criteria, which are reviewed and approved through our Utilization Management Committee. We rely on providers’ clinical notes and supporting documentation to make fair, consistent, and medically appropriate decisions.
Is cost effectiveness a factor in these decisions?
We provide services within our contracted network of providers, but cost is not a factor when determining medical necessity — decisions are based on the member’s benefits and evidence-based clinical criteria.
What skills does this role require?
Strong clinical knowledge and experience are essential, as is knowing how to apply clinical criteria. You also need to understand the business side of healthcare. It’s important to look at who is responsible for services, since different health plans and participating physician groups have different contracts.
Attention to detail is critical, and you need to be able to communicate effectively, since you may have to contact providers’ offices to obtain additional information. UM is a dynamic field, so you must be willing to adapt to changing policies, clinical criteria, contracts, and evolving healthcare practices.
It’s very challenging, and I’m constantly learning about new medical technologies and their clinical indications. I truly love what I do, and I’ve been with L.A. Care for 10 years now.
How does someone break into the field of utilization management?
When I started over 30 years ago, you learned utilization management through experience, building on your previous clinical knowledge. I previously worked in acute care, home health, and home infusion, and those experiences have served me very well.
Although my career didn’t necessarily unfold the way I’d originally planned, every opportunity along the way led me to exactly where I needed to be. I still enjoy learning every day.
What do you like to do when you’re not working?
I have two grandkids aged 5 and 7, so I love spending time with them. We live near the beach, so we enjoy being by the ocean as well as traveling and attending concerts with our family and friends.
KEITH CARLSON, RN, BSN, NC-BC, has worked as a nurse since 1996 and offers expert professional coaching at www.nursekeith.com.
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