Utilization Management / UM Nurse
Job Title: UM / Registered Nurse (California License) Must be licensed in California- Remote Opportunity
Work Hrs: (8am 5pm PDT) would like to include evening, weekend and holiday coverage.
Length of Contract: 3 months (Temp to Perm possibility)
5 Openings
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 Responsibilities
Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Review 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 guidelines
Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
Meet or exceed productivity targets set forth
Serve as a resource to non-clinical team members when applicable
Qualifications and Education Requirements
Associate's degree in Nursing, preferred
Minimum 2 years of experience in medical management clinical functions.
Working knowledge of MCG, InterQual, and NCQA standards
Please send resume at [email protected]
Apply Now
Work Hrs: (8am 5pm PDT) would like to include evening, weekend and holiday coverage.
Length of Contract: 3 months (Temp to Perm possibility)
5 Openings
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 Responsibilities
Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Review 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 guidelines
Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
Meet or exceed productivity targets set forth
Serve as a resource to non-clinical team members when applicable
Qualifications and Education Requirements
Associate's degree in Nursing, preferred
Minimum 2 years of experience in medical management clinical functions.
Working knowledge of MCG, InterQual, and NCQA standards
Please send resume at [email protected]
Apply Now