Utilization Management Nurse - 238776

Medix is currently hiring for a remote Outpatient UM Nurse for a Healthcare organization that provides all aspects of managed care management services to Independent Physician Associations (IPAs) and hospital clients. This position is fully remote but must have a California nursing license (LVN or RN). We are looking for previous Prior Authorization experience from a health plan. MCG for criteria.

Schedule - Monday - Friday (8a-5p) PST

Summary

Reporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities
• Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required
• Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
• Prevent hospitalization when possible and appropriate
• Provide for continuity of care
• Ensure appropriate levels of care are received by members
• Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business
• Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers
• Identify complex authorization requests and appropriately refer to Case Management personnel
• Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests
• Maintain prompt and open communication with the Denial team to meet tight turnaround time (usually with 24hours of initial request)
• Communicate with Health Plan Liaisons in the event that a precertification requests requires health plan review, ensuring review is completed in compliance with timeliness standards
• Outreach to Provider Network Operations team to address provider related referral insufficiencies
• Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources
• Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.

Minimum Job Requirements: • Current California RN or LVN license • 2+ years of experience in utilization management either from an MSO, or a health plan • Prior Authorization experience is a plus • Proficiency with Microsoft Office Programs; primarily Word and Excel

Apply Job!