Utilization Management Nurse

Job Objective:
To manage utilization of health care resources by effectively assuring whole quality-of-care and service.

Description of Duties:


Regularly and on a daily basis, exercises independent judgment and uses specialized background, training and experience to assure efficient function  of managing ambulatory utilization of health care and to provide medical information to assist with various reporting requirements, by performing the following tasks with little or no supervision;

 

1. Review and approve referrals as indicated using appropriate criteria.  Refer medically complex, high cost, high risk referrals and all denials to Medical Director.

 

2. Review all inpatient activity for appropriateness of medical necessity, level of

  care, length of stay and disposition of members in Plan and/or out of plan

  facilities.  

 

3. Maintain accuracy and timely input of utilization data into HMS.  Maintain

  appropriate logs.

 

4. Identify high risk/catastrophic cases through various sources and open cases in a

  timely manner.

 

4. Interact with Benefits Specialist and Clerk to facilitate prior authorization

  process.

 

5. Keep Director of Health Services apprised of significant trends and challenges

  in the referrals.

 

6. Attend various committees/meetings as assigned by the Director of Health Services.

 

7.  Participate in projects and other duties as assigned by the Director of Health   Services.

Minimum Requirements:


Education: Bachelor of Nursing preferred.

Licensure:  Current California Nursing license required.

Knowledge:  HMO, commercial, PPO and self-insured health benefit plans.

ClinicalExperience:  Two years acute/critical or ER care experience and utilization/managed care (HMO) experience preferred.