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Nurse, UM Criteria (LVN or RN)

Desert Oasis Healthcare
Palm Springs, CA Full Time
POSTED ON 1/26/2025
AVAILABLE BEFORE 3/25/2025
The Utilization Management (UM) Criteria Nurse is responsible for reviewing referral requests and supporting documentation to accurately pull medical necessity criteria by utilizing established hierarchy protocols. The UM Criteria Nurse is responsible for approving designated referrals based on organizational and departmental policies, procedures and business rules. This individual interfaces with organizational leadership and physician reviewers to facilitate timely referral request review and decision.
  • Pre-screens assigned specialty consultation referrals and Preauthorized Referral Forms to confirm accuracy.
  • Identify authorization request with insufficient supportive documentation and obtain necessary documentation for a determination to be rendered. Make recommendations on what additional documentation would be helpful to facilitate review decision while monitoring turn-around-time compliance.
  • Review completed referral documentation for accuracy and completeness prior to forwarding to the appropriate physician reviewer for final determination.
  • Respond to emergent and urgent authorization requests with priority and within established timeframes.
  • Ensure that all referrals are processed within established turn-around-times to maintain compliance with health plan requirements.
  • Serve as a liaison between UM Medical Directors, UM physician reviewers and referral coordinators when prior authorization issues or questions arise.
  • Serve as a clinical resource for the Referral department staff regarding issues and or questions pertaining to interpretation of benefits, referral/physician requests and notes interpretation.
  • Approve certain referral authorizations in accordance organizational and UM departmental policies, procedures and business rules.
  • Review referral to ensure that they are accurate, timely, processed correctly and verify that all clinical data pertains to the correct member.
  • Perform other duties as assigned.
(11335)

  • Graduate of an accredited nursing program.
  • Current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license.
  • 3 years progressive clinical nursing experience. 3 years of Quality or Utilization Management (UM) experience, preferred.
  • Knowledge of basic nursing practices and protocols.
  • Knowledge of EZ CAP and NextGen, preferred.
  • ICU and Medical-Surgical background, preferred.
  • Must be able to work independently and possess strong clinical skills.
  • Detailed oriented and well-organized. Ability to manage time effectively and prioritize tasks to meet established deadlines.
  • Ability to communicate effectively with individuals within all levels of the organization, patients, providers, vendors and others.
  • At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.

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