Utilization review nurse Jobs in Visalia, CA

Position Title : Registered Nurse Utilization Management

Location : Remote

Shift Type : (8am – 5pm PDT) Workdays / Hours : Would like to include evening, weekend and holiday coverage.

Contract Duration : 3 Months ( Temp to Perm Possibility)

Overview :

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum

ROLE AND RESPONSIBILITIES

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid / Medical criteria, InterQual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
• Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
• Meet or exceed productivity targets set forth
• Serve as a resource to non-clinical team members when applicable

QUALIFICATIONS AND EDUCATION REQUIREMENTS

Working knowledge of MCG, InterQual, and NCQA standards