Sr. Utilization Management Nurse

Job Locations US-CA-Aliso Viejo
Req No.
2018-2329
Category
Clinical/Medical
Type
Regular Full-Time

Overview

ConcertoHealth delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups.

The ConcertoHealth name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.

 

Summary:

This position is responsible for promoting the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to authorization requests for outpatient services and inpatient admissions.

Responsibilities

  • Responsible for implementing and coordinating all utilization management functions relating to the authorization of outpatient services and supplies, as well as hospital care.

 

  • Ensures that authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized guidelines and evidence based standards.

 

  • Evaluates authorization requests received for scheduled inpatient elective admissions, ambulatory surgeries and outpatient services and supplies.

 

  • As needed, forward requests to the Physician Advisor, ensuring that the member is receiving the appropriate care in the correct setting, while making sure regulatory guidelines are followed. 

 

  • Utilizes designated criteria along with clinical knowledge to process authorization request and assists with review determinations.

 

  • Initiates and maintains direct communication with health care providers involved with the care of members to obtain complete and accurate information.

 

  • Applies appropriate benefits information to determine if requested services are a covered benefit under the member’s Health Plan.

 

  • Applies clinical knowledge and experience to process requests for services and supplies.

 

  • Identifies members appropriate for case management and makes timely referrals to the Care Management department.

 

  • Identifies potential quality of care issues and refers to the Quality Department.

 

  • Meets service standards for turn-around times for decisions and written correspondence.

 

  • Assists in training and mentoring new staff.

 

  • Supports the supervisor with various leadership activities including preparation of quick reference guides and training materials.

 

  • Works collaboratively with the Clinical Training team on process improvement activities as well as audits and the development of training materials.

 

Qualifications

License / Certification: Requires a valid, unrestricted state nursing license (RN or LVN).

Education: 1 year of leadership experience in a health care setting. 
 

Experience: Four (4) years’ utilization management experience preferred.  Must possess a strong understanding of Managed Care including referral requirements.

 

1 year of leadership experience in a health care setting.

Computer Skills: Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system.  Knowledge / Skills / Abilities: High energy; demonstrates an ability to function in a creative, entrepreneurial environment and “think outside the box.”

 

Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.

 

Knowledge of healthcare delivery and management.

 

Able to demonstrate strong knowledge of the authorization review process and workflow.

 

Intermediate computer literacy (MS Office) and typing skills are necessary.

 

Strong interpersonal and decision-making skills; must be able to introduce new ideas, processes, and tools to improve department performance.

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