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Utilization Management Nurse

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

Job Description:

Utilization Management Nurse Location: Santa Barbara, California, , United StatesJob ID: Posted: 03/04/2019Position Title: Utilization Management NurseCompany Name: CenCal HealthSector: HospitalEntry Level: falseFull-TimeSanta Barbara, CA, USAReq Number: UMNUR01069DescriptionThis 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 QualificationsSkills Preferred: Microsoft OfficeExperience Preferred: Prior utilization and/or case management experience in an inpatient, clinic health plan and/or managed care settingCertification in utilization review or healthcare managementCertified Case ManagerTo apply and learn more:

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

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