Pediatric Utilization Management RN - Health Plan

Location: Santa Barbara, CA
Date Posted: 08-01-2018
Pediatric Utilization Review RN - Managed Care
Santa Barbara, CA
Your Job Summary:
The Pediatric Utilization Review Nurse is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review. The UR Nurse will performs reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. They will conduct prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests.
Your Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Your Background
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
CCM or CPUR/CPUM/CPHM or similar certification is preferred
Roughly 1-2 years acute care clinical nursing experience is required.
Around 1-2 years of recent experience in Pediatric Utilization Review or Care Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Your Duties:
As a Utilization Review Nurse you will utilize your clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.  You will assist the provider in identifying appropriate options for the level of care that will assist the member in achieving optimum stability of health. Interact telephonically with employers, patients, physicians and facilities to determine medical status, type of immediate care needed and future care needs.  You will telephonically review inpatient hospital admissions and assist with the coordination of discharge planning needs. You will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.  You will evaluate the options and services required to meet the member’s health needs, in support and collaboration with disease management interventions.  You will perform prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests. Perform concurrent review to assure appropriateness of admission, continued inpatient/acute rehabilitation/SNF status, and discharge using established Milliman or Interqual guidelines or industry standards.  Collect pertinent documentation and conduct medical services review applying appropriate criteria, including national standardized criteria and local plan rules and guidelines.  Consult with Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval.  Make referrals as indicated to case management, disease management, or behavioral health.  Collaborate with the Disease Management, Quality Management, and Case Management departments in the development of protocols and guidelines designed to standardize care practice and delivery. 
Erik Berg
443.470.8240 (CALL – TEXT – FAX)
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