Utilization Management Nurse (UM Nurse)
Division: Managed Care Operations
Department: Care Management
Location: Los Angeles California 90028
Job Summary:
The Utilization Management Nurse (UM Nurse) is responsible for projecting and integrating the
Mission and Core Values of the organization in the provision of utilization management services
to members and medical providers of Healthcare Foundation’s Medicare Health Plan,
Medi-Cal Health Plan and where designated, Ryan White Programs.
Key responsibilities of the UM Nurse include but are not limited to:
1. Making decisions as to the level of care necessary and appropriate for the patients,
whether to approve or present for modification or denial to the Medical Director
specific admissions to acute or skilled facilities, modes of inpatient or outpatient
treatment, diagnostic testing or medications. Such decisions may cover the health plan
members as well as uninsured or underinsured patients within the managed care
environment.
2. To reduce fragmented care and readmissions by coordinating the patient, patient care
givers, inpatient discharge team and next level of care transitioning interdisciplinary
team needed to implement the patient-centered transition from the acute or skilled
nursing facility to the next level of care after an episode of illness or medical
intervention.
3. Applying professional, national, contractual, regulatory, and Plan standards to
utilization management decisions on a consistent and non-biased patient centered
manner.
Essential Duties & Responsibilities
Includes the following:
- Maintaining current knowledge and proficiency in Medicare and MediCal utilization
- management guidance, regulations and contractual requirements as they relate to prior authorization/coverage determinations, redeterminations, exception processes and
- appeals.
- Performs pre-admission, concurrent inpatient and retrospective reviews to determine
- whether an admission is, or remains to be, reasonable and medically necessary using
- Medicare, Medi-Cal, InterQual® and/or company Best Practice criteria and guidance.
- Requests clinical information within 24-hours of notification of an inpatient admission.
- Demonstrated ability in utilizing relationship management, coordination of services,
- resource management education, patient advocacy, and other related interventions to:
- Assure the receipt of timely information related to utilization management is received from hospitals, nursing facilities, medical providers and other health care entities.
- Promote improved quality of care and/or life.
- Promote cost effective medical outcomes.
- Prevent hospitalization/readmission when possible and appropriate.
- Prevent complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for all members.
- Assure medically indicated and appropriate levels of care are received by members.
- Identify quality of care issues.
- Performs case reviews in a timely manner and notifies providers of determination within
- 72-hours of clinical decision.
- Reviews PHC acute care admissions for medical necessity. Reviews initial and continuing
- care PHC acute care Treatment Authorization Request (TAR) against information
- provided during concurrent review for accuracy and approves or refers case to Medical
- Director for denial or administrative day conversions. Documents all rationale for
- decision making in appropriate software system and the TAR prior to submission to
- Medi-Cal.
- Will assist with the transition from partial to full risk for the Medi-Cal HMO plan product
- line, including admission and concurrent review along with discharge planning and
- coordination efforts with facility and care management staff. Will participate in the
- updating and drafting of policies to reflect operational shifts in accordance to this
- transition.
- Collaboration with the Primary Care Provider and/or attending physician,
- RNCTM/LVNCTM and other team members both internal and external, along with any
- additional appropriate health care team members to facilitate the care transition, care coordination, member and care giver education, continuity of the care plan and patient
- centered interventions.
- Assists in the discharge planning process with both internal and external case managers/
- discharge planners to assure the transition of care is effective and complete. Will place
- significant focus on providing the Transition of Care Staff with most up to date discharge
- information so that the staff may facilitate scheduling of post discharge visits within 7-
- days with either the member’s PCP or the Health Plan Nurse Practitioner
- Concurrent Review and collaboration with case managers at the acute care setting,
- skilled nursing facilities, acute rehabilitation units, long term care facilities and hospice
- care. Obtains appropriate facility assessment or certification documents as required by
- each level of care and incorporates into the utilization management plan for the
- individual patient, e.g. National Coverage Determinations, MDS SNF Evaluation, Hospice
- Certification/Recertification, etc.
Maintenance of current Medicare and Medi-Cal regulation and requirement knowledge
for:
- Skilled nursing pre-admission evaluation, admission evaluation, continued skilled stay necessity review.
- Long term care admission evaluation, interval assessment and continued stay requirements.
- Organizational determinations, reconsiderations, expedited reviews,
- Independent Review Entity (IRE) reconsiderations, QIO review of coverage terminations, appeals, etc.
- Hospice benefit initial certification and benefit period certification, levels of hospice services and coordination of Medicare/MediCal non-hospice services where necessary.
Assesses each acute hospital admission to determine the appropriate level of care, i.e.,
critical care, telemetry, step down, medical-surgical, administrative, etc.
Assess each SNF or LTAC transition of care for appropriate admission and concurrent
review criteria.
Performs on-site review for acute and/or SNF member admissions, as needed.
Identifies and reports variances to the Manager of Utilization and Case Management.
Coordinates closely with the Plan’s Medical Director, referring cases that do not meet
established criteria, Medicare, MediCal or Ryan White contractual requirements.
Reviews and make decisions on Prior Authorization request. Documents decision
process in UM systems.
Notifies UM Manager and Director of Claims when hospital acquired conditions or any
denial of payment situations occur.
Perform retrospective claims review on admissions the Plan was not informed of or
which require additional clinical review for indications and appropriateness of services.
Documents all findings in UM system.
Maintain accurate documentation of all reviews, interventions, clinical activities and
communications. Maintains organized patient files.
Present comprehensive and up to date inpatient case information at the weekly case
round meeting.
Generate bimonthly in-depth utilization review reports of members admitted for more
than 10-days. Cases will be presented for second level review by the Medical Director,
Director of Care Coordination and Manager of Care Coordination.
Maintains current knowledge of MCO benefit structure, policies and procedures related
to authorization of services. And is adept at creating a wrap around solution to address
member’s needs using appropriate MCO benefits and available ASO and community
resources.
As a nurse serves as a clinical resource to Utilization Management authorization
coordinators.
Completes a minimum of three recommended AIDS related in-services, trainings or
conferences per year.
Obtains and maintains HIV/AIDS disease/treatment general knowledge
proficiency.
Prepares and distributes a daily inpatient report to Medical Director, Chief of Managed
Care, Associate Director of UM/CM and UM/CM Manager and appropriate company staff as
indicated. Other duties as assigned.
- Participation in company Meetings/Committees
- Participate in weekly Care Management/ICT Rounds.
- Lead daily Utilization Review Rounds
- Monthly Department Meeting
- Utilization Management Committee
- Monthly Managed Care Staff Meeting
- Attends other company meetings as assigned.
Supervisory Responsibilities
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty
satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or
ability required. Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential functions.
Education and/or Experience
- Graduate from an accredited RN Program required.
- 3 or more years of acute hospital experience with adults in medical/surgical, critical care or ER
- HIV/AIDS nursing experience desired.
- 2 or more years of recent Utilization Review/Case Management experience desired but willing to train a candidate with strong clinical background.
- Medicare and Medi-Cal Utilization Management knowledge preferred.
- InterQual® experience a plus
- Managed Care experience a plus.
- Computer/Software Skills & Abilities
- To perform this job successfully, an individual should have knowledge of Contact Management systems,
- and basic knowledge of business software. Must know how to access a document in Word or Excel.
- Must be able to enter data and save a document in Word and Excel. Must have the ability to type a
- minimum of 35 words per minute. Ability to input data in Access database in a pre-designed form.
- Ability to access and research Internet Explorer. Understands the process to access Outlook to verify
- emails. Knowledge of MS Visio a plus.
Language Skills
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and
legal documents. Ability to respond to common inquiries or complaints from customers, regulatory
agencies, or members of the business community. Ability to write speeches and articles for publication
that conform to prescribed style and format. Ability to effectively present information to top
management, public groups, and/or boards of directors. Bilingual Spanish a plus.
Mathematical Skills
Certificates, Licenses and Registrations
Current California Nurse License. Willingness to obtain Florida and Georgia Licensure
Current Driver’s License with proof of liability insurance.
ACRN Certification within 2 years of employment
CPUR, CPUM or CPHM, CCM within 2 years of employment.