RN UM Clinical Intake Coordinator

Job Description

RN Clinical Intake Coordinator is responsible for supporting the clinical Utilization Management activities for members. Conducts medical necessity review of referral requests including but not limited to requests for DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. Utilizes Milliman and Medicaid criteria to facilitate decision making. Refers cases to the Medical Director when clinical information does not support medical necessity. Functions as a key resource to the Non-Clinical Intake Coordinators for questions or clarifications on criteria, interpretation of benefits, or whenever they need additional clinical expertise and / or guidance.

Education and experience :

• Registered Nurse (RN) with an active, current, unrestricted CA license required
• Minimum of two years (2) full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required.
• Bachelor’s Degree from an accredited school or equivalent in Nursing
• Understanding of utilization management principles required
• Experience with MCG Health LLC clinical guidelines and Medi-CAL coverage required
• Experience working in case management or care coordination preferred
• Knowledge of Kern County Community resources for seniors and people with disabilities preferred