Outpatient Utitlization Management Nurse
The Outpatient Utilization Management (UM) Nurse is responsible for conducting clinical reviews of outpatient authorization requests. The Outpatient UM Nurse works directly with members, case management, Authorization Unit Specialists (AUS) and providers in assessing and providing appropriate services to achieve positive health outcomes. The goal is to improve members’ quality of life and ensure cost-effective outcomes by utilizing all available resources.
Principal responsibilities include:
• Provide timely clinical review of authorization requests using clinical policies and procedures and nationally recognized evidence-based clinical review guidelines.
• Assess members’ health care status.
• Identify members with medical conditions that may meet California Children’s Services (CCS) eligibility and coordinate with the CCS specialist for referral.
• Assess members’ health history, risks, and utilization.
• Coordinate care with subcontracted providers.
• Coordinate with family and caregivers as appropriate.
• Coordinate the interdisciplinary approach to providing continuity of care, including utilization management and transfer coordination for Agnews members and/or members who reside in Senate Bill 962 and SRH homes.
• Receive, process, and review prior authorization requests for facility admissions for outpatient services and inpatient elective procedures.
• Coordinate with Medical Services staff for members receiving inpatient care to assure appropriate discharge plan and follow up.
• Participate in case management and care coordination projects.
• Provide on call coverage during the weekend when required.
• Provide clinical support and guidance to the AUS staff.
• Communicate, as needed, with the Alliance Medical Director to validate patient acuity and plan of care; refer authorization requests for potential denial to the Medical Director.
• Complete other duties and special projects as assigned.
EDUCATION OR TRAINING EQUIVALENT TO:
• Active and unrestricted California Registered Nurse License or California Licensed Vocational Nurse License required.
• Have a cleared TB test prior to or within seven days of hire.
• Current CPR and first aid card prior to or within six months of hire is preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
• Three years of experience in clinical case management or discharge planning.
• Three years clinical experience in an acute care setting.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
• Experience providing case management services.
• Case Manager Certification desirable.
• Managed care experience preferred (HMO or IPA).
• Knowledge of Medi-Cal and Medicare regulations.
• Knowledge of and experience with community partners and other related resources (i.e., Regional Centers and CCS).
• Experience in a medical/public health setting preferred.
• Ability to communicate well with members, providers, and team members.
• Ability to prioritize case load.
• Ability to work within a broad systems perspective.
• Excellent verbal and written communications skills.
• Working knowledge of CPT, ICD-10, and ICD-9.