Job Abstract

The Utilization Management Nurse Specialist RN II will facilitate, coordinate, and approve 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 on site admission and concurrent review, and collaborates with on site 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 inquires in a professional and courteous manner.

Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment.

Perform telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate Inbound requests that are received from providers. 

Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.

Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs.  Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.
 
Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. 
Documents in platform/system of record. Utilizes designated software system to document reviews and or notes. 

Receive 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 inquires in a professional and courteous manner.

Perform other duties as assigned. 

Required:
At least 5 years of varied clinical experience in an acute hospital setting. At least 2 years 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.

Required:
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint.  Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate  software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. 

Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team  
 
Excellent time management and priority-setting skills.

Maintains strict member confidentiality and complies with all HIPAA requirements.

Strong verbal and written communication skills.    

Preferred:
Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). 

Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.

May work in occasional weekends and some holidays depending on business needs