Utilization Management Nurse Specialist RN II (ALD)

L.A. Care Health Plan•Los Angeles, CA

6d•$88,854 - $142,166

About The Position

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. The role ensures timely and accurate determinations and notifications for referrals and reconsiderations, and generates approval, modification, and denial communications for members and providers. The specialist monitors inpatient admissions and performs telephonic and/or onsite admission and concurrent reviews. In collaboration with onsite staff, physicians, providers, and members and their families, the specialist develops and implements discharge plans. The role works with the UM Manager and Physician Advisor on pre-service, concurrent, post-service, and retrospective claims medical reviews. It also monitors the collection and transfer of medical records and referral requests, and serves as a department resource for medical service requests and referral management processes. The position receives provider calls, handles complex inquiries professionally, researches timely and accurate resolution steps, and follows up with callers. It supports a positive and productive workplace and performs other duties as assigned.

Requirements

Associate's degree in Nursing.
At least 5 years of varied RN clinical experience in an acute hospital setting.
At least 2 years of Utilization Management or Case Management experience in a hospital or HMO setting.
Active, current, and unrestricted California Registered Nurse (RN) license.
Computer literacy, including expertise in Outlook, Word, Excel, and PowerPoint, and the ability to use appropriate software and interact with L.A. Care information systems.
Ability to use a personal computer, keyboard, and appropriate software to produce correspondence, charts, spreadsheets, and other information applicable to the position.
Ability to prepare clear, comprehensive written and oral reports and materials.
Excellent customer service skills for frequent communication with providers and other members of the interdisciplinary team.
Excellent time management and priority-setting skills.
Ability to maintain strict member confidentiality and comply with HIPAA requirements.
Strong verbal and written communication skills.

Nice To Haves

Bachelor's degree in Nursing.
Managed Care experience performing Utilization Management and Case Management at a medical group or management services organization.
Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management.
Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services (CMS) requirements for health plan compliance with Utilization Management or Care Management.
Certified Case Manager (CCM).

Responsibilities

Promote and support team engagements, programs, and activities to help create and maintain a positive and productive workplace.
Perform telephonic and/or onsite admission and concurrent reviews and collaborate with onsite staff, physicians, providers, members, and significant others to develop and implement discharge plans.
Process, finalize, and facilitate inbound requests received from providers.
Generate appropriate member and provider communications for determinations within timelines defined by current department policy.
Facilitate and review requests for higher levels of care, skilled nursing, and discharge planning.
Research appropriate facilities, specialty providers, and ancillary providers for all lines of business, and identify potential areas for improvement within the provider network.
Identify and initiate referrals for members to L.A. Care programs, external community-based programs, and linked or carve-out services, such as DDS, CCS, and MH.
Identify and document potential quality-of-care and fraud issues according to L.A. Care policy.
Maintain high-risk and high-cost cases and reports and refer them to the Physician Advisor or UM Director.
Document reviews and notes in the designated platform or system of record.
Monitor the collection and transfer of medical records and provider referral requests.
Receive provider calls, handle complex inquiries professionally, research resolution steps, follow up with callers, and answer inquiries courteously.
Perform other duties as assigned.