Utilization review nurse Jobs in Fontana, CA

Riverside Medical Clinic Utilization Management Role

Come and join the RMC Family! We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

Summary

Responsible for the processes of evaluating the necessity, appropriateness, and efficiency of outpatient / ambulatory services per health plan and regulatory standards. Assists the Manager of Medical Management and / or the Regional Director of Quality Risk & Utilization Management in preparing required documentation for Health Plan audits and appeals. This role entails overseeing a team of utilization review nurses and coordinators, ensuring compliance with clinical regulatory standards, and enhancing the overall utilization review process to optimize patient care and manage resources effectively. Provides training and service recovery with direct reports, including the supervision of the day-to-day activities of subordinates by assigning workload, reviewing prospective / pre-service utilization review records, reviewing cases referred to the physician advisor, and providing technical guidance on unusual cases. Ensures accuracy of eligibility, benefits, and services for the referral process as per health plan and regulatory standards.

Qualifications

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements below represent the required knowledge, skill, and / or ability. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Qualifications EDUCATION and / or EXPERIENCE : A high school diploma or general education degree (GED) is required. A minimum of three (3) years of HMO and insurance experience is required. Supervisor experience and associate degree preferred. Must possess good written and verbal communication skills, ten-key, and excellent computer skills with Excel and Word. Medical terminology is preferred. CERTIFICATES, LICENSES, AND REGISTRATIONS : Candidate must be a Licensed Vocational Nurse (LVN), Registered Nurse (RN) preferred.

Essential Functions

1. Responsible for the collection of accurate data from utilization of services within the Utilization Management Department. Analyzes pre-service cases for referral to the physician advisor to ensure the requested service is based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters. 2. Confers with physicians, administrative personnel, and other disciplines to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures. Resolve escalated issues from external and internal customers. 3. Establishes work procedures and evaluates processes for improvement. Monitor staff production and turnaround time on a daily, weekly, and monthly basis to ensure accuracy, production, and attaining department goals. 4. Prepare and authorize work schedules for UM Coordinators, maintain attendance records, and update payroll systems. 5. Develop and implement monthly utilization statistics, as necessary, for use in the Utilization Management Department and Utilization Management Committee. 6. Determines the need for and conducts in-service training to improve the quality of pre-service / pre-certification reviews, and to disseminate information concerning new or revised procedures. 7. Reviews utilization review records for completeness, use of appropriate codes, the correctness of primary reason and indication for the service / referral requested, and inclusion of all relevant supporting medical information. 8. Review and update authorizations on the system to ensure timely turnaround and compliance with health plan requirements. 9. Serves as a technical resource person to direct reports concerning Federal and State regulations on Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards. 10. Responsible for interviewing, hiring, training, coaching, counseling, and termination of employees. 11. Conduct introductory assessment and annual performance evaluation as required. 12. Ensure all documentation of employee issues, training records, and any related company policies and procedures comply with governmental and company protocol. 13. Conduct monthly staff meetings. 14. Assists the Regional Director of Quality Risk & Utilization Management and / or the Manager of Medical Management in determining staffing needs.