General Summary: Utilization Management Nurse focuses on the Gonzaba Medical Group UM Review Process. 

Supervisory Responsibilities: This position has no supervisory responsibilities.

General Requirements: All duties performed will be done accurately and in a timely manner.

1. Carries out GMG UM Program activities and UM Operations.
2. Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
3. Participates in educational programs as needed.
4. Maintains strict confidentiality practicing HIPAA rules and regulations.
5. Other duties as assigned.
6. Bilingual English/ Spanish fluency preferred.
7. Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
8. Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.

Essential Job Responsibilities:

1. Provides clinical perspective/input to Review team, UM team and Referral Specialists.
2. Summarizes medical records documentation for physician medical necessity review.
3. Composes Denial letters according to CMS defined standards and according to UM delegation rules.
4. Applies evidenced-based criteria to medical necessity reviews and documents appropriately in review summary.
5. Performs daily authorization oversight to insure proper completion of referral documentation in EZ Cap and EMR, timeliness of determinations and compliance with UM Delegation requirements in daily operations.
6. Pulls, validates, and submits ODAG reports, Part C reports and other UM reports to health plans upon request, meeting submission deadlines.
7. Successfully performs live ODAG reviews with health plan auditors; successfully responds to “desk review” requests, by submitting screenshots and documents within defined timeline.
8. Contributes to delegation audits and fulfilling certain requirements for UM delegation related to making UM criteria available to requesting providers upon request, non-contracted providers are consistently identified appropriate State, OIG, MCR opt out screenings are carried out prior to approving the referral service. Ensure use of Board-Certified Specialists in making referral decisions. Other UM requirements for training, monitoring performance measures, etc.
9. Ensures GMG UM team responds timely to inquiry from claims vendor where an authorization has NOT been obtained previously.
10. Identifies opportunities for operational improvement, and works collaboratively with UM team, Provider PODS, and other GMG departments.
11. Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers.
12. Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed.
13. Promotes the Contracted Network Providers to GMG patients and staff.

Education and Training: Active, unencumbered Registered Nurse with an associate degree or must be state-licensed practical nurse with one year of LVN or RN clinical experience. Prefer BS in Nursing. Must keep all licenses and certifications current and in good standing as initial and continued employment is contingent up these credentials. 

Experience: Requires at least 5 years’ experience in Managed Care, and Utilization Management. Experience in a clinic, doctor’s office or hospital with a minimum of one-year acute care experience preferred. 

Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Work Environment: Office environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.