UM Nurse Manager

Job Summary:

• Ensures that the team are properly trained to conduct medical necessity reviews on incoming Pre-Service/Prior-Authorization, Retrospective and Post Claims reviews on Urgent/Expedited and Routine/Standard referrals/authorizations requests in compliance with any Federal, State, Health Plan, Accreditation (URAC, NCQA) requirements.
• Assures staff accountability through routine evaluation, reporting and performance observation, and through timely, thorough preparation of annual review.
• Ensures that staff achieves performance goals while adhering to applicable internal and external policies, procedures, rules and guidelines.
• Ensures that the UM team documents on the Medical Management System in a timely manner, all supporting clinical information, outreach attempts (if applicable) and criteria used to make a determination.
• Adheres to compliance with all federal, state, health plan and accreditation by all laws, standards and regulations.
• Collaborate with hospital/facility staff, providers, coordinators, Medical Director, members and their care givers to provide the level of care necessary to meet member’s health needs.
• Maintain an active role in ensuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners/ case managers or other staff in the early identification discharge needs/disposition and determining appropriate level of care placement.
• Monitor, track, and report any trending inappropriate referrals/authorization to the UM Medical Director and/or the Director of Medical Management.
• Ensure network provider steerage and happening on OON network request and negotiate with Clinic Operations as appropriate.
• Identify and manage high risk members for readmission or with complex medical and psychosocial needs.
• Collaborate with Case Management Team to coordinate post discharge care and services to ensure timely outpatient follow-up, and the provider treatment plan, medications & outpatient services are in place prior to discharge.
• Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process such as National Coverage Determination (NCD), Local Coverage Articles (LCA), Local Coverage Determination (LCD), California Coverage Determinations, Health Plan Medical Coverage Policies, MCG, NCCN etc.
• Contribute to program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the program procedures for conducting UM activities.
• Demonstrate proficiency with the principles and methodologies of process improvement.
• Strategically apply these in the execution of responsibilities in support of a process focused approach.
• Participate on UM Committee meetings and annual health plan audit.
• Other duties as assigned.

Required Skills & Experience:

• Registered Nurse (RN) in the State of California.
• At least 3 to 5 years of Nursing Management Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.
• At least 5-10 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.
• Computer experience in MS Word, Excel and MS Office Programs.
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
• Proven and effective problem-solving, critical thinking, and decision-making skills.
• Collaborative, team-oriented approach to decision-making.

Preferred Skills & Experience:

• 2 to 3 years of UM Manager Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.