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RN - Utilization Management

Allmed Staffing Inc

RN - Utilization Management

Palm Desert, CA
Full Time
Paid
  • Responsibilities

    A large managed care organization is seeking an experienced Utilization Management Nurse to manage one - two Acute Hospitals and perform concurrent review on patients of medical group.

     

    Note: Employer requires you must be fully vaccinated for COVID-19

    Work Location: Currently REMOTE due to Covid. Must reside/be licensed in CA

    Pay: $40.00

    Contract Dates: 12/13/2021 to 3/12/2022

    Hours: Mon-Fri, 8-5 (40 hours a week with these days and hours)


    Responsibilities

    • Collect case specific member information, review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services.
    • Review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care of delivery, and the need for planning subsequent care for contracted members and their eligible dependents as assigned.
    • Providing clinical and managed care expertise, as well as Medical Director/physician consultation.
    • Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Prospective Review Urgent/ Non-urgent, Concurrent Review, Early initiation of discharge coordination, and Analyze case-specific patient information.
    • Verify eligibility, as applicable, and past utilization history.
    • Review case-specific patient information concurrently for the medical necessity of Acute Hospital admissions using commercial review criteria and/or scripted guidelines.
    • Based on severity or complexity of the enrollee's condition, ability to meet commercial review criteria and or scripted guidelines, the necessary treatment, and the discharge planning activity (not routinely conducted on a daily basis), the nurse reviewer will assign the appropriate LOS days/ visits/ services in review of the clinical information obtained.
    • Telephonic discussions with health care providers and members to explain medical necessity determinations using MCG and to obtain additional clinical information.
    • Review clinical coverage reviews and assure client recommendations, as designated.
    • Manage workload to ensure timely processing per state and federal mandates.

    QUALIFICATIONS

    • Active and unrestricted California RN license
    • Prior experience with Concurrent Patient review in an Acute Hospital or Skilled Nursing Facility (SNF) setting.
    • Experience with Referral/Authorization management in a Managed Care setting is a plus.