Utilization Management Nurse Trainer
The primary role of the Utilization Management Nurse Trainer is to ensure that all UM nurse staff is appropriately trained on all health care services. Making sure that UM nurse functions are administered with quality, cost efficiency, and within compliance. By continuously working with the UM nurses and UM Nurse Manager, the entire UM team can perform reviews and audits of patient treatment files. The UM Nurse Trainer will ensure that nurses can identify unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.
Job Duties
This position is responsible for preparing and providing training to ensure the Utilization Management Nurses are prepared to complete the following listed functions and tasks:
Review clinical information for medical necessity determinations of provider service requests for the inpatient and outpatient services.
Perform initial and ongoing reviews for inpatient admissions, level of care, observation, pre-service, concurrent review and discharge planning in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements.
Process requests for prior authorization of outpatient services in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements.
Conduct all medical necessity clinical reviews in Customer’s care management platform for full transparency and tracking of Nurse activities and performance measures.
Participate in department meetings, training, and audit activities equal to Customer employees.
Role/Education Requirements
Active California RN License
Minimum of 2 years of recent health plan experience
High level of expertise in UM services
Experience with MediCal and LA County procedures and policies (preferred but not required)
Experience with MCG Criteria (preferred but not required)
Role Details
Job Type: Contract
Pacific business hours, Monday through Friday
Evenings, weekends or holiday coverage, as needed
Work Location: Remote