Utilization Management Review Nurse

Clever Care Health Plan•Huntington Beach, CA

47d•$75,000 - $85,000•Remote

About The Position

The Utilization Review Nurse will evaluate medical records to determine medical necessity by applying clinical acumen and the appropriate application of policies and guidelines to urgent and standard reviews. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Requirements

Graduate from an Accredited School of Nursing.
Active state's LPN/LVN or RN license.
Three (3) years of utilization review experience in a Health Plan, IPA, or MSO.
Two (2) years of clinical nursing experience
Knowledge of utilization management principles and healthcare managed care.
Experience with medical decision support tools (i.e. InterQual, MCG, NCD) and government sponsored managed care programs.
Strong organizational, task prioritization and delegation skills.
2-3 years of experience using Windows-based programs and MS Office suite, including creating spreadsheets and pivot tables in Excel, presentations in PowerPoint, and documents in Word
Knowledge of required regulatory timelines to ensure department compliance with State and other regulatory contracts.
Knowledge of basic computer applications with ability to adapt to new software programs.
Excellent communication and people skills.
Excellent typing skills.
Strong writing skills.

Nice To Haves

Bachelor's degree in nursing preferred.

Responsibilities

May provide any of the following in support of medical claims reviews, appeal reviews, and utilization review practices.
Completes medical necessity reviews for requested services using clinical judgment and refers cases to Medical Directors when needed
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Enter and maintain pertinent clinical information in various medical management systems
Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
Conducts research necessary to make thorough/accurate basis for each determination made
Work on special projects related to utilization management as needed
Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations
Audit case reviews to ensure compliance with utilization management policies and procedures
Assist with the development of utilization management workflows, policies, and procedures
Participates in all required training
Assist with training for new hires and continued development of existing staff
Serve as a back up to direct manager as needed
Participate in daily census review process and productivity review for staff.
Other duties as assigned