UM Nurse Reviewer, RN - Bakersfield

Description

Location: Bakersfield, CA 93309 (Onsite)

Classification: Full-Time

Schedule: Monday-Friday 8am-5pm

• Medical
• Dental
• Vision
• Simple IRA Plan with Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

The initial pay range for this position upon commencement of employment is projected to fall between $31.00 and $38.74 for a California Licensed LVN & $43.35 and $54.18 for a California Licensed RN
. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Under the guidance of the Utilization Management, the UM Nurse Reviewer will leverage expertise to conduct timely reviews of pre-certification and/or concurrent requests, aligning with established policies. The UM Nurse Reviewer holds responsibility for ensuring that members receive suitable care at the right time and location, all while adhering to federally and state regulated turnaround times.

This role involves reviewing services to guarantee the fulfillment of medical necessity, applying clinical knowledge to ensure proper benefit utilization, facilitating secure and efficient discharge planning, and collaborating closely with internal and external stakeholders to address the multifaceted needs of the member.

• Performs utilization review activities, including pre-certification, concurrent, and/or retrospective reviews according to regulatory guidelines.
• Reviews proposed hospitalization, home care, and inpatient / outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.
• Determines medical necessity of each request by applying appropriate medical criteria to designated level reviews and utilize approved evidence-based guidelines or criteria.
• Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type.
• Answers Utilization Management directed telephone calls, managing them in a professional and competent manner.
• Refers case to Medical Reviewer when the request does not meet medical necessity per guidelines, or when guidelines are not available.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information.
• Sends appropriate system-generated letters to providers and members.
• May provide guidance and coaching to other UM nurses and participate in the orientation of newly hired staff.
• Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
• Identify and refer potential cases to Disease Management and Case Management Team.
• For concurrent referrals, ensure that all post-discharge care is coordinated appropriately according to the needs of the member and ensures appropriate continuity of care.
• Participates in Patient-Centered quality improvement initiatives.
• Participates in monthly/quarterly and annual audits.
• Maintain knowledge of DOFR (Disposition of Financial Responsibility), Medicare guidelines, MCG, Inter Qual, health plan guidelines, and other necessary UM resources.
• Assist in developing workflows, job aid, standard operating procedures, and/or policies and recommend or change as appropriate to ensure timely, efficient, and effective outputs including NCQA, CMS, and other regulatory agencies.
• Participates in data collection, health outcome reporting, clinical audits, and programmatic evaluations.
• Supports patient care database by entering new information as it becomes available, verifying findings and backing-up data.
• Track and trend patient care logs for all required health plans, as needed.
• Ensures clinical documentation is thorough and includes information on transition of care needs of members transitioning from one level of care to another.
• Works with the other support team personnel in a collaborative professional manner to best service the company.
• Identifies high-risk members and conduct necessary interventions, which may include immediate follow-up with Primary Care Physician, community resources such as transportation assistance or programs such as Meals on Wheels for dietary support.
• Present member cases during Multidisciplinary Rounds to provide update and recommendations on member care status and needs to facilitate safe discharges and prevent avoidable delays during admissions.
• Facilitates access to necessary care by navigating barriers and…