Job Description
High Desert Medical Group is seeking a full time Utilization Management Nurse Reviewer. This employee will evaluate the appropriateness of healthcare services, ensuring patients receive necessary care while managing resources effectively. They will examine medical treatments and interventions to ensure they are necessary and effective, conducting audits and reviews.
Summary of Duties: - Understand, promote, and audit the principles of Utilization Management (UM) to facilitate the right care at the right time in the right setting.
- Be familiar with UM requirements of NCQA and the health plans and implement them accordingly.
- Be familiar with the contractual arrangements of the organization to provide steerage to the appropriate settings and providers.
- Identify trends or issues in the UM processes that require further evaluation for their quality or utilization implications and bring these items to the attention of the UM Physician/Medical Management Administrator/Administrator.
- Communicate effectively and interact with the provider group, staff and health plans daily or as indicated regarding UM and referral authorization issues.
- Review and analyze organized UM logs and other related information.
- Participate in monthly UM meetings to disseminate new information.
- Assist the UM Physician with communications, training, meetings, protocol, etc.
- Verify that the process in place for collecting data for referrals is followed via regular audits of the staff's production.
- Verify that the process in place for applying medical necessity criteria is followed via regular audits of the referral process.
- Verify that the denial process in place is followed and compliant via regular review of the denial letters.
- Perform other duties as assigned.
The pay range for this position at commencement of employment is expected to be between $29.00 - $39.93/hr, non-exempt; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
- High school graduate or equivalent.
- Current California Licensed Vocational Nurse (LVN) or Registered Nurse (RN) licenses.
- Three to five years of managed care experience in a medical group or IPA office preferred.
- Experience with health plan audits/compliance and NCQA requirements preferred.
- Knowledge of healthcare and managed care preferred.
- Proficient in MS Office Suite (Word, Excel, Outlook, and PowerPoint).
- Excellent written and verbal communication skills.
- Excellent organizational, interpersonal and analytical skills.
- Ability to handle and prioritize tasks in order to meet all given deadlines and productivity goals.
- Ability to responsibly handle matters of a confidential nature.
- Ability to work in a multi-task, high-productive environment.
Job Tags
Full time, Relocation package,