Utilization Mgmt Nurse

Shared Services: Risk Management- (Full-Time, Day Shift) -

Job Summary: The Utilization Management Nurse is responsible for coordinating the pre-authorization, concurrent review, retro clinical review and utilization management process of the Health Plan members.  Negotiates discounted rates for single case agreements for non-preferred providers on urgent, emergent and concurrent cases.  Negotiates with contracted providers for pricing and contract terms.  Establishes policies, procedures and protocols through research, development, implementation and monitoring of criteria for inpatient, outpatient procedures, tests, durable medical equipment (DME), etc.  For Health Plan benefit determination.  Participates as clinical advisor for Health Plan Level 1 Appeal Committees.  Performs other duties as needed. 

Education and Experience: Associate's Degree in Nursing required. Bachelor's Degree in Nursing preferred. Minimum two years of Acute Care Hospital experience required. Hospital utilization review or case management experience preferred.

Knowledge and Skills: Appropriate levels of care, Utilization Review (UR), Utilization Management (UM), Case Management (CM), claims familiarity, clinical pathways, billing and coding regulations. Ability to analyze and interpret data; judge and act on analysis of data; apply mathematics to manipulate/analyze data; analyze and solve specific problems; Able to read; write and speak with professional quality; use computer and software programs necessary to the position, e.g., Word, Excel, Power Point, Access; operate/troubleshoot basic office equipment required for the position. Able to relate and communicate positively, effectively, and professionally with others; provide leadership; be assertive and consistent in enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently; perform basic math and statistical functions; manage multiple assignments; compose written material; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.

Licensures and Certifications: Active California Registered Nurse (RN) license required.  Certified Professional in Healthcare Management (CPHM), Certified Professional Utilization Review (CPUR) or Certified Professional Utilization Management (CPUM) preferred.