Clinical Nurse Specialist

2 days ago

Long Beach, California, United States Advanced Medical Manage Full time
Job Title: UM Nurse, LVN

Job Summary:

The UM Nurse, LVN will be responsible for conducting prospective and retrospective reviews of requests for service authorizations to monitor the continuity and coordination of care. This position will also assist in the utilization of appropriate services and oversee the Prior Authorization Coordinators to direct appropriate utilization and data.

Key Responsibilities:

  • Medical Necessity Review: Determine compliance with pre-established medical necessity criteria applying Milliman and Healthcare Management Guidelines.
  • Authorization Review: Redirect members for alternative treatment/service that are appropriate to the member's condition after reviewing with the UM Manager or Medical Director.
  • Case Identification: Identify cases requiring potential or actual use of medically inappropriate interventions and refer to the UM Director & Medical Director for review.
  • Productivity: Process a minimum of auths per day.
  • Provider Interaction: Interact with providers for medical information necessary to adjudicate authorizations.
  • Authorization Verification: Review authorizations and verify if the clinical history supports the service/procedure requested.
  • Denial Review: Review potential denial of service with the UM Director & Medical Director.
  • Investigation: Investigate and follow up on all requests for additional information by UM Manager and/or Medical Director.
  • Coordination: Be the primary resource for the Prior Authorization Coordinators.
  • Education: Educate providers as needed with the Authorization/Referral process.
  • Urgent Requests: Be the primary point of contact with providers on urgent authorization requests.
  • Quality Reporting: Identify and report to the QM Department of any potential quality of care issues and/or pre-established UM referral indicators.
  • Confidentiality: Maintain confidentiality on all member medical/clinical information.
  • Additional Duties: Perform other job duties as necessary to accommodate departmental change, workload, and/or emergencies.

Requirements:

  • Language and Communication: Language and communication skills, must be able to communicate both orally and in writing, have the ability to read and comprehend simple instructions.
  • Mathematical Skills: Mathematical skills have the ability to add, subtract, multiply, and divide in all units of measure using whole numbers, common fractions & decimals. Have the ability to compute rate, ratio, percent, and to draw and interpret bar graphs.
  • Decision Making: Be able to recognize and properly handle confidential health information. Be able to efficiently prioritize multiple high-priority tasks. Define problems and collect data, establish the facts, and draw a valid conclusion. Interpret an extensive variety of technical instructions in mathematical form.
  • Computer Skills: Have knowledge of the Internet, MS Word, and Excel. Knowledge of office machinery (phones, fax machines, etc). And the willingness and capacity to learn new software tools when necessary.
  • Education and Experience: Must have graduated from an accredited Nursing program. Must have current CA LVN license. One to two years related experience of education and experience. Experience using MCG Criteria.

Company Overview: Advanced Medical Manage is a leading healthcare management company dedicated to providing high-quality services to our members. We are committed to excellence and strive to make a positive impact on the lives of our members and communities we serve.

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