UM Review Nurse LVN or RN

Company: Cedars Sinai
Location: Beverly Hills
Posted on: May 13, 2022

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.

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