Utilization Review Nurse

Utilization Review Nurse

• Only open to candidates residing in California
• Opportunity to make a difference in your community
• Position not eligible for sponsorship

The Utilization Review Nurse will conduct Utilization Reviews to ensure HPSM members receive medically necessary healthcare in a timely and cost-effective manner. This position will be working closely with a team comprised of Authorization Specialists, Medical Directors, Care Coordination Nurses, Care Coordination Technicians, Concurrent Review Nurses, Care Transition Coaches, and Pharmacists.
Externally, the Utilization Review Nurse will work closely with HPSM’s special programs, community partners and providers to support appropriate referrals for care and resources and coordinate across the care spectrum. The goal of the Utilization Management program is to improve the members’ quality of life and assure cost-effective outcomes by utilizing all available and appropriate resources.

Position overview

• With a clear understanding of the complete member care continuum, perform the primary functions of UR review using standardized clinical guidelines by working collaboratively with provider network.
• Think critically about member needs by understanding the care continuum.
• Understand daily operational reporting that reflects on work efficiencies and outcomes.
• Collaborate cross-functionally with a base level of understanding of Care Coordination, Inpatient Concurrent Review, and Care Transitions.
• Applying continuous process improvement principles by pro-actively communicating improvement opportunities to supervisor.
• Review authorization requests within specified timeframes.
• Review authorization requests for out-of-network providers
• Clinically validate the medical appropriateness of services referred or rendered and triage appropriate cases with clinical documentation for medical director review.
• Utilize appropriate resources to guide review decisions and document decisions clearly and concisely.
• Conduct coordination of care across the different disciplines and settings, contacting and establishing links with physicians, other providers, and community resources.

Requirements
These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

Education and experience

• Five (5) years clinical nursing experience.
• Experience with utilization management, disease management, and coordination of care within a managed care environment is preferred.
• A Bachelor’s degree in nursing or a related health services field is a plus.

License and Certification:

• A valid California license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN)

Knowledge of:

• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• San Mateo County provider community and community resources.
• Medicare and Medi-Cal coverage requirements and regulatory guidelines.
• Utilize Access, Microsoft Office programs; perform internet research.

Ability to:

• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks
• Ensure medical appropriateness and effective utilization of health care resources.
• Maintain timely compliance with all UM regulatory mandates.
• Ensure provider conformance to HPSM UM guidelines.
• Coordinate health services for members transitioning from one level of care to another.
• Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies and the general public.
• Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds.

Salary and benefits
The starting salary ranges: $39.14 - $51.86 per hour for LVN’s and $43.05 - $57.05 per hour for RN’s, depending on the candidate’s work experience.

Excellent benefits package includes:

• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 13 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program

Health Plan of San Mateo (HPSM) is a local County-funded nonprofit manages the health care for over 140,000 low-income people San Mateo County, including all its Medi-Cal eligible residents. HPSM is proud to be an Equal Opportunity Employer and an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.

Job Type: Full-time

Pay: $39.00 - $56.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Utilization review: 1 year (Preferred)
• Clinical Nursing: 5 years (Required)

License/Certification:

• RN (Preferred)

Ability to Commute:

• South San Francisco, CA 94080 (Required)

Work Location: Hybrid remote in South San Francisco, CA 94080