Intensive Case Management - Medicare Advantage Utilization Review Nurse (flexible-hybrid)

Description

Under the direction of the Assistant Director, the ICM Medicare Advantage Utilization Review Nurse performs utilization review of medical necessity and appropriateness, cost containment and efficiency, compliance with regulations and contracts, care coordination and continuity of care, prior authorization and denial management, education and provider support, and data and quality reporting for referrals for Medicare Advantage population enrolled under UCLA Medical Group. The ICM Medicare Advantage Utilization Review Nurse ensures that home health and durable medical equipment services are cost effective, timely, and compliant. This position is a vital role in balancing member quality care with efficient resource utilization under the UCLA Medical Group Utilization Management guidelines. In this role, you will work collaboratively with the patient, Faculty Practice Group, community resources, other providers, managed care operations, the UCLA Health System, and health plans to implement, identify, coordinate, and monitor options and services to meet at-risk patients' healthcare needs.

Qualifications

Required:

• BSN or MSN degree

• Active CA RN License

• Minimum of 2 years' experience in utilization management, Inpatient CM or clinical Experience.

• Strong knowledge of CMS guidelines, home health coverage criteria, and DME regulations.

• Proficient in clinical documentation review, critical thinking and evidence-based decision making.

• Familiarity with utilization platforms and electronic health records.

• Must have strong problem-solving skills. Ability to analyze problems and formulate plans, solutions and a course of action given changing circumstances.

• Excellent organizational and time management skills, including the ability to handle multiple conflicting priorities simultaneously. Strong ability to prioritize.

• Demonstrate proficiency in computer skills such as Windows computer function, computer navigation, and ability to use computerized patient care systems.

• Competence in navigating the internet/intranet and use of browser software such as Microsoft Explorer and applications such as Excel, Word, and PowerPoint

• Excellent interpersonal, verbal and written communication skills. Ability to articulate clinical and non-clinical information to individuals of all levels of understanding.

• Ability to be flexible and work according to availability of office personnel, patient and resources required to coordinate care of patient.

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