Utilization Management Admissions Liaison RN II
Full Time Regular
Los Angeles, 90017
The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regulator timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests.
Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs.
- Excellent time management and priority-setting skills.
- Maintains strict member confidentiality and complies with all HIPAA requirements.
- Strong verbal and written communication skills.
- Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM.
- Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.
- Licenses/Certifications Required
- Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred
- Certified Case Manager (CCM)
- American Case Management Association (ACM)
About the Hospital
As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.
Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.