UM Reviewer Nurse

Job Title: UM Reviewer Nurse (California License) – Must be licensed in California- Remote Opportunity Work Hrs : (8am – 5pm PDT) would like to include evening, weekend and holiday coverage. 3 month contract plus (Temp to hire) Remote Opportunity Ready to Hire ASAP .JD: 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 Responsibilitie sPerform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of member sReview 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 guideline sCollaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determination sEnsure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable .Meet or exceed productivity targets set fort hServe as a resource to non-clinical team members when applicabl eQualifications and Education Requirement sAssociate's degree in Nursing, preferre dMinimum 2 years of experience in medical management clinical functions .UM Reviewer in patient experience require dWorking knowledge of MCG, InterQual, and NCQA standard s