Utilization Management Nurse, RN (Remote)

Inland Empire Health Plan•, CA

1d•$91,250 - $120,910•Remote

About The Position

The Utilization Management Nurse conducts prospective, concurrent, and retrospective reviews of referrals to assess medical necessity and appropriateness of services and care, using nationally recognized utilization management criteria. The role ensures regulatory requirements are met, including readability and appropriate citation of criteria in Member correspondence, and works to meet Members’ needs. The position operates under the general direction of the Utilization Management Manager and collaborates with UM Medical Directors on reviews and final determinations. The nurse supports IEHP’s Quality Program, including goals related to HEDIS, CAHPS, and NCQA Accreditation. The position is telecommute-based, though periodic in-person attendance at IEHP’s main campus may be required for mandatory meetings or other business needs. The listed annual pay range is USD $91,249.60–$120,910.40.

Requirements

At least two years of direct, hands-on clinical patient care experience in an acute care facility using an active RN license.
High school diploma or GED.
Active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN.
Knowledge of nationally recognized UM criteria.
Knowledge of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements as they relate to UM and Health Plan correspondence.
Knowledge of clinical nursing practice, standards of care, and medical terminology.
Knowledge of medical necessity standards and benefit interpretation.
Clinical assessment and documentation skills, including accurate documentation of UM referral reviews.
Written and verbal communication skills.
Critical thinking skills.
Ability to abstract and interpret medical information from clinical records.
Ability to convey information and detailed instructions accurately and quickly.
Ability to manage a caseload efficiently, maintain attention to detail, and work quickly while maintaining accuracy.
Ability to work well with physicians and nursing staff.

Nice To Haves

Experience in an HMO or managed care setting.
Bachelor’s degree in nursing from an accredited institution.

Responsibilities

Conduct prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services and care, including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and high-dollar cases.
Screen medical information and authorization requests against current criteria and discuss findings with Medical Directors.
Review referral denials, denial letters, and logs to assess denial appropriateness, possible alternative treatment, and potential case management or quality-of-care issues.
Collaborate with the UM Medical Director on reviews and final determinations.
Draft denial language to support consistent application of nationally recognized UM criteria and appropriate use of denial language.
Translate medical terminology into plain language and assess reading level as appropriate.
Work with Medical Directors to support consistent use of guidelines and criteria.
Create and maintain a standardized matrix of denial language by Line of Business for internal and external use.
Partner in the letter of agreement process when referring Members to out-of-network providers.
Review and report quality review findings with UM Management monthly to support accuracy and productivity requirements.
Obtain additional medical necessity information and research issues to assist Medical Directors with benefit interpretation; support the UM Team with benefit interpretation and understanding of UM policies and procedures.
Support Medical Directors with revisions to IEHP UM Subcommittee Guidelines to ensure appropriate interpretation of criteria.
Attend staff meetings and education trainings to maintain current nursing and UM knowledge.
Participate in LEAN activities in support of department goals.
Assist with the utilization management section of the Medical Management audit and with focused referral and denial audits.
Perform other duties as required to support Health Plan operations and department business needs.