UM Review Nurse LVN or RN
Company: Cedars Sinai
Location: Beverly Hills
Posted on: May 13, 2022
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Job Description:
Share Requisition # HRC0871912
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.
Minimum job requirements/competencies
* Requires a LVN, or RN with valid unrestricted license in the
state of California
* Minimum 3 years in a managed care setting with 2 years of
Outpatient Utilization Management required.
* Knowledge of Utilization Management Guidelines required.
* Knowledge of the medical management process required.
* Certification as a Case Manager (CCM), Utilization Review,
Managed Care or similar; desired
* Knowledge of ICD-10, CPT, HCPCs
* Familiarity with managed health care programs including HMO, PPO,
and POS.
* Knowledge of NCQA regulations preferred.
* Previous utilization and/or quality management and/or call center
experience helpful.
* Working Title: UM Review Nurse LVN or RN
* Department: MNS UR/CM
* Business Entity: Medical Network
* City: Beverly Hills
* Job Category: Patient Services
* Job Specialty: Case Management
* Position Type: Full-time
* Shift Length: 8 hour shift
* Shift Type: Day
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully
discriminate on the basis of the race, religion, color, national
origin, citizenship, ancestry, physical or mental disability,
legally protected medical condition (cancer-related or genetic
characteristics or any genetic information), marital status, sex,
gender, sexual orientation, gender identity, gender expression,
pregnancy, age (40 or older), military and/or veteran status or any
other basis protected by federal or state law. If you need a
reasonable accommodation for any part of the employment process,
please contact us by email at Applicant_Accommodation@cshs.org and
let us know the nature of your request and your contact
information. Requests for accommodation will be considered on a
case-by-case basis. Please note that only inquiries concerning a
request for reasonable accommodation will be responded to from this
email address.
Cedars-Sinai will consider for employment qualified applicants with
criminal histories, in accordance with the Los Angeles Fair Chance
Initiative for Hiring.
At Cedars-Sinai, we are dedicated to the safety, health and
wellbeing of our patients and employees. This includes protecting
our patients from communicable diseases, such as influenza (flu)
and COVID-19. For this reason, we require that all new employees
receive a flu vaccine based on the seasonal availability of flu
vaccine (typically during September through April each year) as a
condition of employment, and annually thereafter as a condition of
continued employment, subject to medical exemption or religious
accommodation. For the same reason, you may also be required to
receive other vaccines such as COVID-19 as a condition of
employment. Cedars-Sinai reserves the right to make modifications
to its required list of vaccines as required by law and/or
policy.
Keywords: Cedars Sinai, Beverly Hills , UM Review Nurse LVN or RN, Other , Beverly Hills, California
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