UM Nurse (California License)

UM Nurse (California License) Must Be Licensed In California- Remote Opportunity

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum. This position is not patient facing, they will be reviewing patient records and providing recommendations.

Role and Responsibilities

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
• Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
• Meet or exceed productivity targets set forth
• Serve as a resource to non-clinical team members when applicable

Qualifications and Education Requirements

• Associate's degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards