UM Nurse (Part Time)

The UM Nurse's responsibilities include, but are not limited to : Level 1 - LVN :

• Conduct clinical review for service requests for medical appropriateness and medical necessity using clinical judgment, independent analysis, and knowledge of medical policies, clinical guidelines, and benefit plans
• Review, triage, and prioritize authorization requests to meet required turn-around times.
• Expedite access to appropriate care for members with urgent or immediate needs using the expedited review process.
• Research member issues and assess member needs related to authorization requests.
• Acquire appropriate clinical records, clinical guidelines, policies, EOC and benefit policy. Accurately applies coding guidelines.
• Develop determination recommendations and present cases to Medical Director (or designee) for potential denial determinations or when Medical Director input is needed.
• Interact with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
• Develop and / or review appropriate documentation and correspondence to member and providers reflecting determination. Ensure documentation is accurate, complete and conforms to established regulatory standards.
• Document all activities as per department practice including entry into automated systems. Recognizes potential quality of care concerns and refers as appropriate.
• Make appropriate referrals to California Children's Services (CCS) and Tri-Counties Regional Center (TCRC).
• Identify and refer members who may benefit from care coordination programs, such as disease management or case management, and make appropriate referrals.
• Attend meetings or meet with staff within the organization as assigned.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.LEVEL 2 - RN : (in addition to above)
• Conduct clinical review for service requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of medical policies, clinical guidelines, and benefit plans.
• Utilizes strong critical thinking skills for complex clinical reviews and care coordination.
• Ensures that assigned health plans are meeting or exceeding Medicare / Medicaid / Commercial performance benchmarks per health plan contracts.
• Builds and maintains relationships with internal and external clinical teams to help resolve barriers to referrals and care.
• Acts as a clinical resource to LVN staff.
• Begins to influence department's strategy and provide constructive feedback to Medical Management leadership.
• Makes decisions on moderately complex to complex issues regarding technical approach for project components, such as Medical Management system enhancements, and work is performed with minimal direction.RequirementsEDUCATION, EXPERIENCE AND QUALIFICATIONSLevel 1 : LVN
• Graduate of an accredited Licensed Vocational nursing program required
• Active, valid, & unrestricted State of California Licensed Vocational Nurse license is required
• Understanding of federal and state regulations / requirements, including HIPPA, and / or JCAHO or NCQA criteria.
• Strong analytical and problem solving skills preferred.
• Excellent verbal and written communications skills, with focus on appropriate clinical documentation.
• A team player who builds effective working relationships but also has ability to work independently.
• Basic understanding of standardized clinical guidelines / criteria (e.g. MCG, InterQual, Medi-Cal Criteria, Medicare Criteria).
• Strong organizational and time management skills.
• Able to operate PC-based software programs including proficiency in MS Word.
• Bilingual (English / Spanish) speaking and writing preferred.Level 2 : RN
• Graduate of an accredited nursing program required (e.g. ASN, ADN, BSN, MSN) Bachelor's degree preferred.
• Active, valid, & unrestricted Active, State of California Registered Nurse license required.
• Understanding of federal and state regulations / requirements, including HIPAA, and / or JCAHO or NCQA criteria.
• Strong analytical and critical thinking skills and ability to identify complex care coordination opportunities
• Excellent verbal and written communications skills, with focus on appropriate clinical documentation.
• Strong understanding of standardized clinical guidelines / criteria (e.g. MCG, InterQual, Medi-Cal Criteria, Medicare Criteria).
• CCM, URAC, or Managed Care Nurse certification, preferred
• Varied background in nurse disciplines, such as acute inpatient care, home health, outpatient clinic, behavioral health and ancillary services.
• Two or more years of experience in a fast-paced insurance or health care setting, preferred.How to ApplySend applications or resume to : CdcrCareers@clinicas.org Fax : 805-659-3217Is this job listing for a Provider?No Learn More