The Utilization Management Nurse Specialist RN II will facilitate, coordinate and approve of medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modifications and denials communications, to include member and provider notification of referral determination.

Actively monitors for admissions in any inpatient setting. Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical…

Qualifications

• Education Required: Associate's Degree in Nursing
• Education Preferred: Bachelor's Degree in Nursing
• Experience Required: At least 5-7 years of varied clinical experience in an acute hospital setting. At least 2 years Utilization Management experience in a hospital or HMO setting. At least 2 years CM experience in a home health, hospice, or HMO setting.
• Preferred: Managed Care experience performing UM and CM at a Participating Physical Group (PPG) or MSO. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Experience with special needs populations.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 LicenseActive & Current Driver's License, …

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.