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Job description
RN Job
Utilization Management Nurse Specialist RN II
Shift
Full Time
Pay Range
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Job ID
13270
Location
Los Angeles, 90017
Job Description
The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination.
Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan.
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes.
Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner.
Qualifications
Education Required
Associate's Degree in Nursing
Education
Bachelor's Degree in Nursing
Experience Required
At least 5 years of varied RN clinical experience in an acute hospital setting.
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting.
Preferred
Managed Care experience performing UM and CM at a medical group or management services organization.
Experience with Managed Medi-Cal, Medicare, and commercial lines of business.
About The Hospital
As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.
Why Join Us
Opportunity
Amazing co-workers
A supportive management team
Great compensation and benefits
Camaraderie and a true sense of mission
If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.
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Worksite address
los angeles, CA, 90079, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.