Utilization Management Nurse, LVN/LPN (Part Time)
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 member’s receive 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.
This is a part time position that requires availability to work weekends (Saturday and Sunday).
ROLE RESPONSIBILITIES
Capacity to perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Capacity to 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
Capacity to collaborate with the Medical Director to ensure the integrity of adverse
determination notices based on the quality standards for adverse determinations
Capacity to ensure discharge planning is timely and appropriately communicated to transition of care teams, when applicable.
Capacity to meet or exceed productivity targets set forth
Capacity to serve as a resource to non-clinical team members when applicable
Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned.
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 California and Unrestricted License as a Licensed Vocational Nurse (LVN)
Certification Managed Care Nursing (CMCN) preferred
WORK ENVIRONMENT
The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
Some travel may be required.
For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $26.35-$39.53 Hourly.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.