Utilization Management Registered Nurse needed for a full-time, direct hire opportunity with Yoh's client located in Santa Barbara, CA.
Position Overview: The UM Nurse performs prospective, concurrent, and retrospective reviews for long- term care, acute inpatient, specialty referrals, medical services and durable medical equipment. The purpose and goals of utilization management are to assure that members receive medically necessary care at the appropriate place, with the appropriate provider, and at the appropriate level of care.
Top Skills You Should Possess:
Active/unrestricted Registered Nurse license in state of California
- Minimum of two years' of case management experience
- Certified Case Manager (CCM) preferred
What You'll Be Doing:
- Accurate interpretation of established clinical guidelines
- Perform timely prospective review for services requiring prior authorization
- Perform timely concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care setting
- Perform timely retrospective review for services that required prior authorization but was not obtained by the provider
- Support and collaborate with the UM and CM Clinical Managers in the implementation and management of UM/CM activities
- Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member’s quality of care
- Perform selective claims review, and occasional onsite review
- Adhere to regulatory time frames for completion of reviews
- Keep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice
What You Need to Bring to the Table:
- Strong organizational skills and excellent verbal and written communication skills
- Prior utilization and/or case management experience in an inpatient, clinic, health plan and/or managed care setting
- Experience working with Medi-Cal patients
- Computer savvy (ie experience with MS Office products)
What's In It For You?
- Competitive pay with opportunities for advancement
- Stable, long-term company that offers a pension plan, professional development and wellness benefits, alternative transportation incentives, and comprehensive medical, dental, vision, and life insurance
*Ask me about our REFERRAL BONUS program!*
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Recruiter: Marine Kokoshyan
Email: Email blocked - click to apply
Long Term Care