D-SNP Utilization Management RN

D-SNP Utilization Management RN

Remote - MUST live in California with active and unrestricted CA license

Description :

The Utilization Management (UM) RN for the D-SNP program plays a critical role in ensuring members receive timely, medically necessary, and cost-effective care.

What You Will Do :

• Conduct Clinical Reviews and Authorization Determinations :
• Review and evaluate requests for inpatient, outpatient, and ancillary services for D-SNP members, ensuring medical necessity, cost-effectiveness, and alignment with the D-SNP Model of Care using evidence-based criteria such as MCG guidelines, Medi-Cal criteria, and CenCal Health policies.
• Perform timely and accurate utilization management reviews, including :
• Selective claims reviews and other case types as indicated.
• Retrospective (post-service) reviews.
• Concurrent reviews in acute, subacute, skilled nursing, and long-term care settings.
• Prospective (pre-service) prior authorization.
• Compose accurate and timely draft notices of action, non-coverage, and other regulatory notifications in accordance with Medicare Advantage and Medi-Cal requirements.
• Maintain comprehensive documentation in care management systems, including case review summaries and proper citation of clinical sources.
• Manage denials and appeals, coordinating with providers, members, and compliance teams to ensure proper resolution.
• Coordinate Care and Support Member Outcomes :
• Collaborate daily with physicians, interdisciplinary care teams, and other providers to assess treatment plans and address complex medical, functional, cognitive, and psychosocial needs of D-SNP members.
• Apply utilization review principles and evidence-based guidelines to promote care continuity across settings, including skilled nursing and long-term care.
• Participate in interdisciplinary team rounds, care transition planning, and post-discharge coordination to reduce avoidable hospitalizations and support member well-being.
• Coordinate with Pharmacy, Quality Improvement, Health Programs, and other internal departments to ensure integrated care and appropriate use of resources.
• Participate in on-call rotation, including weekends and holidays, to ensure timely response to QIO appeal actions (within required regulatory timeframes).
• Ensure Regulatory Compliance and Quality Standards :
• Serve as a liaison to providers and internal teams, promoting understanding of utilization management processes, operational standards, and D-SNP-specific requirements.
• Identify and escalate potential quality of care concerns, collaborating with Medical Management leadership and quality teams.
• Support data collection, audits, and reporting to meet CMS, DHCS, and internal compliance standards.
• Uphold member confidentiality and adhere to HIPAA and other relevant laws and regulations.
• Stay informed about current federal, state, and D-SNP program guidelines related to utilization management.
• Support Education and Continuous Improvement :
• Educate providers and internal staff on coverage determinations, appeals processes, and alternative treatment options in alignment with D-SNP requirements.
• Assist in the development, implementation, and evaluation of quality improvement initiatives and departmental projects aimed at improving D-SNP performance and member outcomes.
• Contribute to internal process improvement and workflow optimization within the utilization management program.

You Will Be Successful If :

What You Will Bring :

About Impresiv Health :

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!