USRN - BPO | California License Holder | Remote Set Up | Urgent Hiring
The role of the UM Nurse is to promote quality and cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and ensuring members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.
Role and Responsibilities
Perform prospective, pre-service medical necessity reviews for an assigned members.
Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare, Medicaid/Medi-Cal, Milliman, or Health Plan specific guidelines
Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
For concurrent review, ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
Meet or exceed productivity targets set forth
Serve as a resource to non-clinical team members when applicable
Qualifications and Education Requirements
USRN with California License is required
Minimum 2 years of experience completing medical necessity reviews.
Working knowledge of applying MCG criteria
Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
Certification Managed Care Nursing (CMCN) preferred
