The RN, Utilization Management Referral nurse will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines. The RN, UM Referral nurse will support the UM leadership team to provide guidance for processing of referrals. The RN, UM Referral Nurse may review retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. The RN, UM Referral Nurse may be involved in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting. The RN, UM Referral Nurse may provide oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable. The RN, UM Referral nurse serves as the lead UM Referral nurse and supports the leadership team in maintaining compliance with regulatory guidelines.

Qualifications

• Current valid License as a Registered Nurse through the appropriate issuing state agencies.
• Minimum of 2 years of managed care experience
• Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.
• Exceptional oral and written skills.
• Excellent customer service; ability to be an effective communicator
• Excellent critical thinking, deductive reasoning and decision making skills.
• Ability to work as a team member and participate in the assessment and evaluation process of potential and existing participants.
• Fosters a cooperative and harmonious working climate conducive to maximize employee morale and productivity.
• Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.
• Ability to work collaboratively with diverse individuals and situations, including strong problem solving and conflict resolution skills.

About the Hospital

Work boldly. Live brilliantly. Bold decisions and innovative thinking have helped AltaMed become the nation’s largest network of community-based primary care facilities and senior care programs. We are a TJC-accredited health system focused on preventative medicine and the elimination of health care disparities throughout Southern California.

At AltaMed, we empower nearly 3,200 employees in medicine, nursing, social work, dentistry, mental health, and health administration to work boldly – bringing their best ideas and greatest strengths to our facilities every day – and to live brilliantly, applying that same energy and purpose to their lives and communities outside.

Explore our opportunities throughout Los Angeles and Orange counties and take your career to the highest level.