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Utilization Management Nurse

Company: CenCal Health
Location: Santa Barbara
Posted on: March 14, 2019

Job Description:

Location: Santa Barbara, California, , United StatesJob ID: Posted: 03/04/2019Position Title: Utilization Management NurseCompany Name: CenCal HealthSector: HospitalEntry Level: false

Full-Time
Santa Barbara, CA, USA
Req Number: UMNUR01069

Description
This 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
    • Identify members appropriate for California Children's Services (CCS) and facilitate referrals
    • 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

      Qualifications

      Skills Preferred: Microsoft Office

      Experience Preferred:

      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

      To apply and learn more:

      Keywords: CenCal Health, Santa Barbara , Utilization Management Nurse, Healthcare , Santa Barbara, California

      Click here to apply!

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