Clinical Utilization Management Liaison RN II
4 weeks ago
**Job Summary**
The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving and reviewing admission requests and higher levels of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post-admission to issue a determination based on clinical criteria for medical necessity. Ensures timely and accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate levels of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation and coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests and referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews.
**Key Responsibilities**
* Provides the primary clinical point of contact for inpatient acute care hospitals requesting inpatient care/post-stabilization admission requests, higher levels of care transfers, and other emergent transfers or needs.
* Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed.
* Triages and assesses members for admission needs, including bed and accepting physician availability.
* Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer.
* Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement.
* Applies clinical expertise and the nursing process to triage and prioritize admission acuity, serving as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes.
* Continually seeks new ways to improve processes and increase efficiencies.
* Completes all inpatient and discharge planning requests appropriately and timely, including skilled nursing facility, outpatient needs, and case management referrals.
* Performs prospective, concurrent, post-service, and retrospective claim medical review processes.
**Requirements**
* Associate's Degree in Nursing
* Minimum of 7 years of clinical experience in an acute hospital setting
* Previous experience in Utilization Management/Case Management practices, including placement (with level of care) criteria, concurrent review, and discharge planning
* Strong understanding of clinical data and medical necessity
* Excellent communication and interpersonal skills
* Ability to work in a fast-paced environment and prioritize tasks effectively
**Preferred Qualifications**
* Bachelor's Degree in Nursing
* Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background
* Experience in bed placement decision-making
* Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM
* Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services (CMS) requirements for health plan compliance with UM or CM
* Certified Case Manager (CCM) certification
**L.A. Care Health Plan Benefits**
* Paid Time Off (PTO)
* Tuition Reimbursement
* Retirement Plans
* Medical, Dental, and Vision
* Wellness Program
* Volunteer Time Off (VTO)
**Salary Range Disclaimer**
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
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