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UM Review Nurse LVN or RN

Location: Beverly Hills
Posted on: May 10, 2022

Job Description:

Are you ready to bring your expert clinical skills to a world-class facility recognized as top ten in the country? Do you have a passion for the highest quality and patient happiness? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you.UM/Medical Management Clinical Nurse is responsible for working with healthcare providers, pharmacist reviewer, physician reviewers, and medical directors to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to pre and/or retro authorize services, assess medical necessity, out of network services, and appropriateness of treatment setting by applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. The UM/MM Clinical Nurse collaborates with providers and clinical practices/offices (PCP and specialists) to promote the most appropriate, highest quality and effective use of clinical services to ensure quality member outcomes, and to optimize member benefits. This position is also responsible with optimization and integration of member services, network management, provider and member relations, marketing, training/development, resource management, as it may relate to the respective clinical practice(s)/offices they are assigned to. They work collaboratively with the all of the teams under Care Coordination department and assist the management team with special projects, when needed.ESSENTIAL JOB DUTIES:

  • Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by applying the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
  • Effectively and efficiently review -prior authorizations and retrospective authorizations , -providing updated criteria and necessity, utilizing the appropriate tools and reviewing diagnostics that is and consistent with the members' eligibility, benefits and contract
  • Investigating, processing, and assist with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy
  • Collaboration with clinical teams and practices to ensure synchronization of sub-areas' operations to reach organizational and departmental goals
  • Identify possible adverse selection cases for new members with high cost diagnosis and/or comorbidities.
  • Maintaining and updating the appropriate databases and department tools with current information.
  • Ensure contract compliance and adherence to DMHC, OHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.

Keywords: CEDARS-SINAI, Beverly Hills , UM Review Nurse LVN or RN, Healthcare , Beverly Hills, California

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