The role of the Nurse Reviewer is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization specialty referral requests as well as acute inpatient admission.  The Nurse Reviewer will review for appropriate care and setting, and following guidelines/policies, will approve services when indicated.  

If not indicated, Nurse Reviewer will forward requests to the appropriate physician or medical director with recommendations for other determinations, ensuring that the member is receiving the appropriate quality care in a preferred setting, while making sure regulatory guidelines are followed. Work in collaboration with the Regional Medical Director to thoroughly review member referral history and anticipated needs in an effort to avoid admission. Responsible for identifying possible TOC cases for new members with high cost diagnosis.

The Nurse Reviewer will be responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode as well as prior authorizations (particularly those with facility components). Identifying the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care.

Qualifications

• Graduate from an accredited Registered Nursing Program or Licensed Vocational Nursing Program.
• Current California Licenses
• Minimum of 1 year acute experience
• Knowledge of Healthcare and Managed Care preferred.
• Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
• Knowledgeable with the pre authorization process and workflow, with prior authorization experience preferred.
• Knowledgeable in computers and MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).
• Ability to deal with responsibility with confidential matters
• Ability to work in a multi-task, fast-paced, high-stress environment.

About the Hospital

As one of the largest physician-led networks in Southern California, we have thousands of physicians and hundreds of hospitals committed to providing quality healthcare to all of the communities we serve.

Every day, our employees are inspired to make a difference in the lives of others as well as transform their own experiences to achieve a higher sense of fulfillment. Our employees become a part of an extraordinary team of people dedicated to health, wellness, and happiness for themselves and others. There is no greater reward than contributing to a positive work environment where compassion, understanding, care and attention are encouraged and valued.