Utilization Management Nurse - 238776

Medix is currently hiring for a remote Outpatient UM Nurse for a Healthcare organization that provides all aspects of managed care management services to Independent Physician Associations (IPAs) and hospital clients. This position is fully remote but must have a California nursing license (LVN or RN). We are looking for previous Prior Authorization experience from a health plan. MCG for criteria.

Schedule - Monday - Friday (8a-5p) PST

Summary

Reporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities
?? Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required
?? Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
?? Prevent hospitalization when possible and appropriate
?? Provide for continuity of care
?? Ensure appropriate levels of care are received by members
?? Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business
?? Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers
?? Identify complex authorization requests and appropriately refer to Case Management personnel
?? Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests
?? Maintain prompt and open communication with the Denial team to meet tight turnaround time (usually with 24hours of initial request)
?? Communicate with Health Plan Liaisons in the event that a precertification requests requires health plan review, ensuring review is completed in compliance with timeliness standards
?? Outreach to Provider Network Operations team to address provider related referral insufficiencies
?? Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources
?? Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations.

Minimum Job Requirements: ?? Current California RN or LVN license ?? 2+ years of experience in utilization management either from an MSO, or a health plan ?? Prior Authorization experience is a plus ?? Proficiency with Microsoft Office Programs; primarily Word and Excel

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