Job purpose
The position of Care Management Nurse reports to the Director of Care Management. The position of UM Nurse is part of the Case Management team and is responsible for the 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 or clinical guidelines used to determine medical necessity.
Duties and responsibilities
• Comply with UM policies and procedures. Annual review of UM policies.
• Review & screen incoming service referral requests for medical necessity.
• Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
• Knowledge of health plan DOFRs and contracts and how they apply to the review process.
• Review member' utilization and claim history when processing a referral.
• Apply Correct Coding Initiative as per clinical criteria.
• Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review.
• Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests.
• Daily production standard is a minimum of 50-90 referrals/day depending on complexity with accuracy & quality.
• Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meets criteria and can
be authorized by a nurse level reviewer.
• Act as clinical resources to all departments.
• Communicates with health plans, providers, members and other parties to facilitate member care treatment plan.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients.
• Review claim and referral appeals and forward them to the Medical Director when appropriate.
• Work closely with Claims Manager on overlapping issues such as rates and procedures and CPT codes for new procedures.
• Attend to provider and interdepartmental calls in accordance with exceptional customer service.
• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Always maintains strictest confidentiality.
• Other duties as needed.
Qualifications
• Valid California Licensed Vocational Nurse license.
• 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 of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended.
• Ability to work independently with minimal supervision, exercising judgment and initiative.
• Ability to manage multiple tasks with effective prioritization.
• Process oriented.
• Good computer skills.
Education and Additional Requirements
• Valid California Licensed Vocational Nurse license.
Working conditions
• This job may require flexible work hours due to the nature of the responsibilities
• Candidate must be comfortable with ambiguity and open to working in a collaborate environment
Physical requirements
• Sitting/standing for extended periods of time.
