[Hiring] UM Outpatient Review Nurse @All Care To You

Role Description

The position of UM Outpatient Review Nurse reports to the Director, Case Management. The position is part of the Case Management team and is responsible for clinical, quality, and patient outcomes. This position is expected to implement the effectiveness and best practices of Utilization Review and will provide high quality medical review by appropriately applying the State, Federal, health plan and clinical guidelines used to determine medical necessity.

Duties and Responsibilities

• Review authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for informed consent.
• Process all requests within established time frames.
• Document all steps of the process in the authorization system in the authorization notes.
• Utilize CMS and Health Plan Hierarchy criteria.
• Conduct clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review.
• Perform retrospective review of services to determine medical necessity.
• Refer cases to the Medical Director for review of requests that may not meet medical necessity criteria.
• Process denials within established timeframes.
• Write denial letters to meet CMS and Health Plan requirements.
• Work closely with other MSO team members as necessity requires.
• Apply the appropriate clinical criteria/guideline, policy, EOC/benefit policy, and clinical judgment to render coverage determination/recommendation for the review process.
• Review member’s utilization and claim history when processing a referral.
• Maintain quality reviews while meeting the established TATs for Urgent, Routines, and Retro requests.
• Maintain Interrater Reliability Rate at least 95% or above.
• Meet daily production standard of a minimum of 50-90 referrals/day depending on complexity with accuracy & quality.
• Make approval determinations when requests meet appropriateness, medical necessity, and benefit criteria.
• Utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services that meet criteria and can be authorized by a nurse level reviewer.
• Act as clinical resource to all departments.
• Communicate with health plans, providers, members, and other parties to facilitate member care treatment plans.
• Participate in team training.
• Comply with UM policies and procedures. Annual review of UM policies. Attend to provider and interdepartmental calls in accordance with exceptional customer service.
• Maintain a high level of confidence and discretion when dealing with sensitive matters relating to providers and members. Always maintain strict confidentiality.
• Perform other duties as needed.

Qualifications

• A valid CA and Texas/Multi State Registered Nurse license or Licensed Vocational Nurse.
• CM and/or UM training and/or certification.
• Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines.
• Medi-Cal, Commercial and Medicare contracts and benefit interpretation is preferred.
• Five years+ clinical experience.
• Prefer two (2) years+ experience in an HMO/IPA/Managed care setting.
• Must be available to work weekends and holidays, as business needs require.
• Ability to work independently with minimal supervision, exercising judgment and initiative.
• Ability to manage multiple tasks with effective prioritization.
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel), and Adobe.
• Detail oriented and highly organized.
• Strong ability to multi-task, project management, and work in a fast-paced environment.
• Strong ability in problem-solving.
• Ability to self-manage, with strong time management skills.
• Ability to work in an extremely confidential environment.
• Strong written and verbal communication skills.

Education and Additional Requirements

• Holds Current Unrestricted CA and Texas/Multi State RN or LVN license.

Benefits

• 100% employer paid medical, vision, dental, and life coverage for employees.
• Additional employee paid coverage options available.
• Paid holidays and birthday off.
• Unlimited PTO.
• 401k plan.