Utilization Management Specialist

Facilitation, coordination and approval of medically necessary referrals for direct lines of business (MCLA, Healthy Families, Healthy Kids) that meet established criteria.

- Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.
- Generates approval, modifications and denials communications, to include member and provider notification of referral determination.
- Actively manages cases for applicable cases admitted in the acute or sub-acute settings.
- Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review.
- Monitors and oversees the collection and transfer of data (medical records) and referral requests.
- Acts as a department resource for medical services request/referral management and processes.

SKILLS:

EDUCATION:

- REQUIRED: Registered Nurses (RN) graduate; Associate Degree in Nursing
- PREFERRED: Bachelor of Nursing or health care related field

LICENSES/CERTIFICATIONS

- REQUIRED: RN License, Current, unrestricted California License

EXPERIENCE

- REQUIRED: Clinical Nursing - 3 - 5 years, UM experience particularly in review of inpatient or sub-acute admissions; Utilization Management experience at HMO, hospital or PPG level
- PREFERRED: Managed Care Medical experience, HMO - 3 years