Judge Healthcare is actively seeking full time Utilization Management LVN for California's premier health systems!! This Nurse will specialize in Outpatient Utilization Review.
This position is located in Anaheim, CA!
This job will have the following responsibilities:
The Utilization Management (UM) Nurse is responsible for general, precertification, concurrent and/or retrospective review of inpatient and/or outpatient services.
The Utilization Management Nurse is responsible for the determination of medical appropriateness and medical necessity for a variety of services using evidence-based clinical guidelines and works with providers to meet the health care needs of members with the appropriate resources.
Performs prior authorization and retrospective review according to evidence-based clinical criteria, Medicare Guidelines, and established protocols to determine the medical appropriateness of the request.
Refers cases to the Medical Director, Utilization Management when the treatment request does not meet medical necessity guidelines or when peer-to-peer conversation is necessary
Maintains a thorough understanding of NCQA, URAC, and CMS guidelines for Utilization Management.
Identifies problems or complex cases and refers for possible Care Management intervention and identifies members with chronic disease process for possible disease management intervention.
Coordinates the delivery of cost-effective, quality-based health care services for members. •Assists with the set up and approval of skilled nursing facility or rehabilitation facility per established protocol.
Assists with the set up and approval of Home Health Care or Durable Medical Equipment upon discharge from hospital per established protocol.
Reviews authorization requests and communicates with the physician’s offices when additional information is needed or assists office in re-directing care to an appropriate plan provider or facility.
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