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Utilization Management Nurse - No Nights or Weekends!

Company: CenCal Health
Location: Santa Barbara
Posted on: November 28, 2018

Job Description:

Utilization Management Nurse - No Nights or Weekends! Location: Santa Barbara, California, 93101, United StatesJob ID: Posted: 11/20/2018Position Title: Utilization Management Nurse - No Nights or Weekends!Company Name: CenCal HealthSector: HospitalEntry Level: falseJob Type: Full-TimeUtilization Management NurseShift: Monday-Friday 8:00-5:00Classification: ExemptDepartment: Health ServicesLooking for a career that makes a difference in people's lives? CenCal Health is a locally-run, not-for-profit health plan that serves nearly 180,000 people, with offices in both Santa Barbara and San Luis Obispo Counties. For 35 years, we've been improving the health and well-being of our neighbors through partnership and collaboration, and we're looking for exceptional, mission-driven professionals to help us grow. We are an employer of choice in Santa Barbara, offering competitive salaries, generous vacation & holidays, comprehensive health/dental/vision benefits including a CalPERS pension plan and 457 deferred income plan, a wellness program, a gym in our headquarters and parking lot BBQs. Come join our group of nice people doing good work at a great company.Job SummaryThe UM Nurse performs prospective, concurrent, and retrospective reviews for long- term care, acute inpatient, specialty referrals, medical services and durable medical equipment. The purpose and goals of utilization management are to assure that CenCal Health members receive medically necessary care at the appropriate place, with the appropriate provider, and at the appropriate level of care.Duties and ResponsibilitiesThis position is responsible for timely review of request for services and based on established clinical guidelines and/or benefits limitations, determine appropriateness of requested services.Responsibilities include: Accurate interpretation of established clinical guidelines Perform timely prospective review for services requiring prior authorization Perform timely concurrent review for inpatient care in the acute care, subacute, skilled nursing, and long-term care setting Perform timely retrospective review for services that required prior authorization but was not obtained by the provider Support and collaborate with the UM and CM Clinical Managers in the implementation and management of UM/CM activities Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member's quality of care Perform selective claims review, and occasional onsite review Adhere to regulatory timeframes for completion of reviews Keep abreast of health care benefits and limitations, regulatory requirements, disease processes and treatment modalities, community standards of patient care, and professional nursing standards of practice Other duties as assigned Skills/Knowledge/Abilities Excellent written, oral and interpersonal communication skills Good computer skills with accurate data entry into an electronic health record Ability to analyze medical documentation and apply criteria to determine medical necessity, acuity of care, severity of illness and intensity of service Ability to multi-task, organize and prioritize workload, and complete assignments in a timely manner Knowledge of managed care issues, including benefits and contract limitations, delivery and reimbursement systems, and role of medical management activities Work independently or cooperatively, as a team leader and member Ability to organize work effectively in a cross-functional team environment in a collaborative way Ability to communicate by phone and in person (in both individual and group situations) and to clearly and effectively communicate and negotiate with members and families, physicians and other health care providers Maintain consistent and predictable attendance. Maintain sufficient level of punctuality and attendance to meet job standards and requirements Education and ExperienceRequired: Current valid, unrestricted California Registered Nurse License A minimum of one year experience as a Registered Nurse Must be computer literate Strong organizational skills and excellent verbal and written communication skills Desired: Prior utilization and/or case management experience in an inpatient, clinic, health plan and/or managed care setting Certification in utilization review or healthcare management Certified Case Manager Essential Functions Physical requirements needed to perform the essential functions of this job, with or without accommodation: Mobility Requirements: ability to operate a keyboard and sit for long periods; stand, sit, reach, bend, crawl, stoop, lift up to ten (10) lbs. Visual Requirements: ability to read close-up and do close-up work Dexterity Requirements: ability to perform repetitive motion (keyboard); writing (note-taking) Hearing/Talking Requirements: ability to hear normal speech, hear and talk on the telephone Emotional/Psychological Requirements: ability to deal with public contact, in person and Normal office environment. Must be able to sit and work at a computer for long periods of time Valid California Driver's License with a clean driving record Must be able to travel outside the office and attend meetings during and after regular work hours Regular attendance is essential to perform this job Find Out More About CenCal Health The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.

Keywords: CenCal Health, Santa Barbara , Utilization Management Nurse - No Nights or Weekends!, Executive , Santa Barbara, California

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