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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.

We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

SCOPE OF ROLE

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.

ROLE RESPONSIBILITIES

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
• Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
• Meet or exceed productivity targets set forth
• Serve as a resource to non-clinical team members when applicable

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
• Certification Managed Care Nursing (CMCN) preferred