Utilization Review Nurse

Job Description

Job Description

Utilization Management RN

The UM Nurse’s primary function is to ensure timely review of referral requests, procedure, and pre-certification requests in accordance with established policy. The position is responsible for the appropriate review of authorization requests, concurrent review, following regulatory guidelines, maintaining performance standards and keeping the UM Manager informed of member / provider issues.

Duties include but are not limited to :

1. Review authorization requests, applying clinical criteria based on nationally standardized guidelines and UM criteria in establishing authorization determinations.

2. Prepare and present authorization requests with supporting documentation for review with the Medical Director.

3. Assume responsibility for ensuring timely reviews of authorization requests in accordance with written policy, regulatory, and Health Plan guidelines.

4. Apply case management skills to members who have been identified as high risk for hospital readmissions through telephonic case management.

5. Perform other duties as assigned.

This position requires the following minimum requirements :

• Knowledge of Commercial, Medicare, and Medi-Cal HMO lines of business
• Knowledge of medical coding practices.
• Working knowledge of medical standards of practice or experience with using UM medical criteria (i.e. Milliman and InterQual) required.
• Strong Computer experience including using the internet to research clinical and non-clinical issues required
• Employee must reside in the state of California

Education and Licenses :

Current California RN or LVN license required.

Experience :

Company Description

At Insight Global, we’re more than just a staffing agency — we’re a people-first solutions firm that believes in the power of connection. With a nationwide presence and a reputation built on trust, integrity, and results, we specialize in placing top-tier talent across healthcare, IT, education, engineering, and professional services.

Company Description

At Insight Global, we’re more than just a staffing agency — we’re a people-first solutions firm that believes in the power of connection. With a nationwide presence and a reputation built on trust, integrity, and results, we specialize in placing top-tier talent across healthcare, IT, education, engineering, and professional services.