Utilization Management Nurse, LVN/LPN

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.

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