Utilization Management Nurse

The Utilization Management (UM) Nurse is a licensed nursing professional responsible for reviewing UM cases and discharge planning activities. The UM Nurse may also assist with preparing files for audits and required reporting and ensuring UM cases are reviewed and processed within timeliness standards.

The UM Nurse will work closely with the UM/QI Manager, MSO UM team, MSO Medical Director, and MSO Physician Reviewer on UM case reviews. The UM Nurse will also work with the MSO Case Management team on coordinating patient care to ensure patients can access the necessary medical care to manage their health condition.

• Applies clinical skills and expertise in the assessment, planning, and coordination of necessary healthcare services.
• Reviews Treatment Authorization Request (TAR) and patient treatment plans to ensure adherence to established criteria and standards.
• Responsible for the inpatient UM process, including initial and concurrent case reviews, review of inpatient skilled nursing and rehabilitation treatment requests, and facilitate repatriation efforts.
• Provides guidance to UM Coordinators on complex outpatient TARs that require clinical judgment and application of medical necessity criteria.
• Facilitates timely implementation of hospital discharge plans in collaboration with other interdisciplinary team members; arranges follow‑up care as appropriate.
• Makes complex clinical decisions regarding medical care; involves Medical Directors and clinical providers to solve the complex issues.
• Collaborates with MSO Case Management team and PCPs to ensure resource utilization is appropriate; plans and implements strategies to reduce resource consumption and achieve positive patient outcomes.
• Identifies community and outpatient resources and coordinates with the interdisciplinary team to assist patients in obtaining the needed services.
• Participates in the development and implementation of effective and efficient standards, policies, protocols, reports and benchmarks that support the UM program requirements.
• Utilizes multiple systems to maintain documentation of case activities; collects, analyzes and reports on data for utilization, quality improvement, compliance, and other areas as assigned.
• Assists in training new UM Nurses and UM Coordinators and guides them in accurately completing their work.
• Provides cross coverage for MSO Nurse Case Managers and performs transition of care services, including post‑discharge follow‑up, medication reconciliation, home visit, and screening members for complex case management criteria. Home visits may be conducted at a public place if the patient does not have a home.
• Performs other job duties as required by manager/supervisor.

• Active California Registered Nurse license.
• Current documentation of Basic Life Support is required.
• Valid Driver’sLicense and ability to maintain license preferred.
• Demonstrate willingness to make decisions within RN's clinical scope of practice; exhibits sound, accurate, and ethical judgment.
• Ability to engage and work collaboratively with others, including patients, patient's families, clinical team members, clinical supervisors, and community resources.
• Ability to provide detailed, concise note/documentation of work within workflow turnaround timelines.
• Good communication and interpersonal skills; ability to work with people from diverse backgrounds and experiences.
• Able to spend 20-40 minutes at a time with patient in the community, including at clinics, specialist offices, hospitals, community‑based organizations, or patient’s home which may be in understaffed/remote areas, in the presence of pets or family members that are tobacco users.
• Time management and prioritization skills are vital.

• Must be able to fluently speak, read and write English.
• Fluent in Chinese (Cantonese and Mandarin) preferred.
• Fluent in other languages is an asset.

This is an FLSA Exempt position.
This is not an OSHA high‑risk position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS:
Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).