Job Summary

Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

Functions & Job Responsibilities

• Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.

• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

• Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care

• Conduct discharge planning

• Educate providers on utilization and medical management processes

• Provide clinical knowledge and act as a clinical resource to non-clinical team staff

• Enter and maintain pertinent clinical information in various medical management systems

• Direct care to participating network providers

• Participate in utilization management committees and work on special projects related to utilization management as needed

• Serve as a subject matter expert for questions or issues for other Concurrent Review Nurses and Prior Authorization Nurses

• Audit case reviews to ensure compliance with utilization management policies and procedures

• Assist with the development of utilization management workflows, policies, and procedures

• Research and validate accuracy of lapsed authorization data with staff and provide reports summarizing results

• Lead and facilitate multiple weekly rounds with staff, medical directors, and external contracted providers

• Assist with training for new hires and continued development of existing staff

• Serve as a back up to direct manager as needed

• Participates in daily census review process and productivity review for staff.

• Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

Education & Experience:

• Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred

• 2+ years of clinical nursing experience and 3+ years of utilization management experience in a managed care setting

• Knowledge of utilization management principles and healthcare managed care.

• Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.

• Current state’s LPN/LVN or RN license.

Skills:

• Active driver’s license in good standing preferred.

Physical & Working Environment.

Typical Physical Demands.
Position requires a great amount of driving, sitting and standing. Some standing, stooping, bending or reaching is required. May require lifting up to 15 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.