UM Nurse, LVN

Overview Join to apply for the UM Nurse, LVN role at Advanced Medical Management, Inc. Base pay range $30.00/hr - $40.00/hr This range is provided by Advanced Medical Management, Inc.. Your actual pay will be based on your skills and experience talk with your recruiter to learn more. Position Summary Reports to the UM Manager. This position is a California licensed nurse whose primary responsibilities are to perform the prospective and retrospective review of the requests for service authorizations in order to monitor the continuity and coordination of care and to assist in the utilization of appropriate services. The Prior Authorization Nurse conducts these reviews of authorization requests to verify accurate provider specialties, medical treatments and services, place of service and/or facilities. Also oversees the Prior Authorization Coordinators to direct appropriate utilization and data. Responsibilities & Duties Determines compliance of pre-established medical necessity criteria applying Milliman, and Healthcare Management Guidelines. Redirects members for alternative treatment/service that are appropriate to the members condition after they have been reviewed with the UM Manager or Medical Director. Identifies cases requiring potential or actual use of medically inappropriate interventions and refers these to the UM Director & Medical Director for review. Expected to process a minimum of 100-150 authorizations per day. Interact with providers for medical information necessary to adjudicate authorizations. Review authorizations to verify that clinical history supports the requested service/procedure. Verify authorizations are requested for the appropriate provider and service area. Review potential denials of service with the UM Director & Medical Director. Investigate and follow up on all requests for additional information by the UM Manager and/or Medical Director. Serve as the primary resource for the Prior Authorization Coordinators. Educate providers as needed with the Authorization/Referral process. Act as the primary point of contact with providers on urgent authorization requests. Identify and report to the QM Department any potential quality of care issues and/or pre-established UM referral indicators. Maintain confidentiality of all member medical/clinical information. Perform other job duties as necessary to accommodate departmental change, workload and/or emergencies. Ensure the privacy and security of PHI (Protected Health Information) as outlined in policies and procedures relating to HIPAA compliance. Understand all Medical Management policy and procedures, and NCQA guidelines. Job Requirements Language and communication skills: must be able to communicate both orally and in writing; ability to read and comprehend simple instructions. Mathematical skills: ability to perform basic arithmetic, interpret rate, ratio, percent, and graphs. Decision making: ability to handle confidential health information, prioritize tasks, define problems, collect data, and draw valid conclusions. Computer skills: knowledge of Internet, MS Word and Excel; familiarity with office machinery; willingness to learn new software tools. Must have graduated from an accredited Nursing program. Must have current CA LVN license. One to two years of related experience or education. Experience using MCG Criteria. Amm Benefits Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe. Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays. Career Development: Tuition reimbursement to support your education and growth. Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun Join AMM and experience a workplace where your health, growth, and happiness come first #J-18808-Ljbffr