UM Nurse / Utilization management Nurse

UM Nurse (California License) – Must be licensed in California- Remote OpportunityWork Hrs: (8am – 5pm PDT) would like to include evening, weekend and holiday coverage.Remote Opportunity6 Months (Contract to hire)JD:The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.This position is not patient facing, they will be reviewing patient records and providing recommendations.Role and ResponsibilitiesPerform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of membersReview cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelinesCollaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinationsUM experience should be more on an outpatient setting vs inpatient hospital.Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.Meet or exceed productivity targets set forthServe as a resource to non-clinical team members when applicableQualifications and Education RequirementsAssociate's degree in nursing, preferredMinimum 2 years of experience in medical management clinical functions.Working knowledge of MCG, InterQual, and NCQA standardsPlease send resume [email protected]

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