UM Nurse Case Manager

  • Full Time
  • Pasadena

Imperial Management Administrators Services

The Utilization Nurse is responsible to assure health care services are available to Imperial Health members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.

Responsibilities and Duties

Provides first level clinical review for all outpatient, planned inpatient and ancillary services requiring authorization. Performs retrospective chart review as indicated.
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
Refers those requests that do not meet medical criteria review to the Imperial Health Medical Director or Physician Advisor for second level review and determination.
Completes data entry and correspondence as necessary for each review.
Answers Utilization Management directed telephone calls; managing them in a professional and competent manner.
Processes all prior authorizations to completion utilizing appropriate review criteria.
Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity.
Acts as liaison between the Imperial Health members, network providers Provider Relations Department for contracted health plans.
Screens and refers appropriate health plan members for short term or complex case management, disease management, or other care management strategies as applicable.
Maintains knowledge of and is compliant with current UM Plan and policies & procedures.
Performs quality improvement activities and maintains current quality improvement document as directed.
Perform other duties as assigned.
Qualifications and Skills

Requirements for the Utilization Review Nurse :

Current California RN License or LVN License
3+ years of nursing experience in an acute care hospital setting
3+ years of managed care and utilization review experience
Experience with clinical review
Spanish speaking or other second language a plus!

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