Kelly Healthcare Resources (KHR) specializes in providing highly skilled nursing and allied health professionals within hospitals and other healthcare facilities as well as positions in sectors such as insurance, pharmaceutical, health management and education.
We currently have an exciting full time temporary-to-hire opportunity for a Utilization Management/UM Outpatient Review RN/LVN position in San Bernardino, Ca. Work schedule is Monday-Friday from 8am to 5pm.
RN/LVN POSITION PURPOSE
Under the general direction of the Utilization Management Director, the Utilization Management Nurse is responsible for working directly with the Plan IPAs/Medical Groups and hospitals to ensure coordinated, continuous cost effective quality healthcare for Company's Members.
MAJOR RESPONSIBILITIES 1. Responsible for the oversight and/or performance of authorizations of referrals to a specialist for consultation and treatment under the direction of the Utilization Management Director and Associate Medical Director. 2. Responsible for the oversight and/or performance of prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of service and care. 3. Responsible for the oversight and/or performance of authorization of other outpatient and ancillary services, including but not limited to, outpatient surgery, durable medical equipment, home health, etc. 4. Responsible for the retrospective review of all IPA/Medical Groups referral denials, denial letters, and logs received by Company to determine appropriateness of denial, possible alternative treatment, and evaluation for case management or quality of care issues. 5. Responsible for serving as a resource for Company's Member and Provider Service departments for utilization management, referral and continuity of care issues. 6. Under the direction of the Utilization Management Director, provide one-on-one inservices for IPA Utilization Management Nurses. 7. Assist with the utilization/ case management section of the IPA Operational audits, as well as, focused referral and denial audits, under the direction of the Utilization Management Director. 8. Responsible for follow up on corrective action plans submitted to Company by the IPA/ Medical Groups. 9. Responsible for working with Team Members to support the goals of the department and the vision of the organization. 10. Any other duties as required to ensure Plan operations are successful. 11. Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company's policies and procedures relating to HIPAA compliance.
RN/LVN MINIMUM QUALIFICATIONS
Education/License: Possession of a valid RN/LVN license issued by the State of California. Possession of a valid State of California driver's license. Experience: Two (2) or more years of utilization management experience in a health care delivery setting. Experience in an HMO or experience in a Managed Care setting preferred.
In addition to working with the world's most recognized and trusted name in staffing, Kelly employees can expect: ' Competitive pay ' Access to a comprehensive employee benefits package including health, prescription, vision, dental, life and short-term disability insurance ' Paid holidays ' Portable 401(k) plans ' Bonuses ' Recognition and incentive programs ' Access to continuing education via the Kelly Learning Center
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Kelly Healthcare Resources is a part of Kelly Services, a US-based Fortune 500 company and a global staffing industry leader. Our vast network of branch locations allows us to provide consistent, quality service to healthcare professionals and customers worldwide.
We invite you to bookmark our website and encourage you to review it regularly for new opportunities worldwide: www.kellyhealthcare.com Kelly Services- Celebrating 60 Years Kelly Services is an Equal Opportunity Employer.