Utilization Review Nurse

Serra Medical Group (SMG) was founded in 1974 and is dedicated to providing the highest quality of patient care services under one roof. We are one of the largest, most comprehensive multispecialty physician group practices in the San Fernando Valley. For more information, please visit us at: www.serramedicalclinic.com.

Position: LVN Utilization Review Nurse

Qualifications

At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting

Managed Care experience performing UM and CM at a medical group or management services organization.

Experience with Managed Medi-Cal, Medicare, and commercial lines of business.

Spanish-Preferred

Technical skills: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint

Effectively utilize computer and appropriate software and interacts as needed with Serra Medical group Information System (PCM).

Customer Service Skills: Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team

Maintains strict member confidentiality and complies with all HIPAA requirements

Strong verbal and written communication skills

Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM

Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM

Licenses/Certifications Required

Licensed Vocational Nurse (LVN) - Active, current and unrestricted California License

Responsibilities

The Utilization Reviewed Nurse LVN will facilitate, coordinate, and approve medically necessary referrals that meet established criteria

Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status

Generates approval, modification and denial communications, to include member and provider notification of referral determination

Actively monitors for admissions in any inpatient setting

Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, member/ family interaction to develop and implement a successful discharge plan

Works with the UM Director and Medical director on case reviews for pre-service, concurrent, post-service and retrospective claims medical review

Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers

Acts as a department resource for medical service requests /referral management and processes

Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps

Follows up with caller to provide response or resolution steps

Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment

Perform prospective, concurrent, post-service and retrospective claim medical review processes

Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge and application of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type

Process, finalize and facilitate Inbound requests that are received from providers

Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy

Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs

Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business

Identification of potential areas of improvement within the provider network

High risk/high cost cases and reports are maintained and referred to the Medical director/UM Director

Utilizes designated software system to document reviews and or notes

Participate in the department’s continuous quality improvement activities

Communicates to UM Director barriers to completing assignments or daily work in an efficient and effective manner

Perform other duties as assigned

Job Type: Full-time

Pay: $28.00 - $36.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Employee discount
• Free parking
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Healthcare setting:

• Inpatient

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Utilization review: 1 year (Preferred)

Language:

• Spanish (Preferred)

License/Certification:

• LVN License (Required)

Work Location: In person