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Company: Network Medical Management Inc
Location: Monterey Park
Posted on: January 12, 2022

Job Description:

SUMMARYTo implement the effectiveness and best practices of Utilization Review, the nurse will provide high quality medical care review by appropriately applying the State, Federal, health plan and or clinical guidelines used to determine medical necessity. All reviews are based on established hierarchy of criteria.

  • Comply with UM policies and procedures. Annual review of UM policies.
  • Review & screen incoming service referral requests for medical necessity
  • Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
  • Knowledge of health plan DOFRs and contracts and how they apply to the review process.
  • Work with coordinators to ensure referral is clean and appropriate information available.
  • If possible redirect and or notes required, send to the coordinators to assist.
  • Review member's utilization and claim history when processing a referral.
  • Apply VAE, Correct Coding Initiative as per P&P.
  • Document overview of the members referral request prior to sending to the Medical Director for review
  • Provide Medical Director with specific criteria for the referral based on the hierarchy.
  • Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro services.
    • J Codes: 24 hrs for urgent, 72 hrs for routines
    • Urgents 72 hrs
    • Routines 5 business days- NMM For all HPs/LOB
    • Retros 30 days.
      • Daily production standard is a minimum of referrals/day with accuracy & quality based on years of employment and or UM experience. Numbers may vary based on assignments. 0-6 months: 80-100 Shared Risk: 110-130 Full Risk/MD queues: 90-110
        • Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria;
        • Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meets criteria and can be authorized by UM staff
        • Works closely with the Medical Director to ensure open communication and process.
        • Act as clinical resources to all departments within NMM.
        • Screen for potential California Children Services (CCS) or ambulatory case management referrals.
        • Communicates with health plans/providers/members and other parties to facilitate member care/treatment and to assist in making decisions for the precertification process.
        • Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients.
        • Review claim/referral appeals and unauthorized claims, forwarding them for medical director/UMC review and determination when appropriate.
        • Work closely with Claims Department on overlapping issues such as rates and procedures/CPT codes for new procedures.
        • Identifies potential TPL/COB cases, investigates TPL/COB issues, and notifies the appropriate internal departments
        • Attend to provider and interdepartmental calls in accordance with exceptional customer service
        • Reports to Lead and or Supervisor on activities or problems occurring throughout the day.
        • Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Maintains strictest confidentiality at all times.
        • Works the MD queue to ensure correct denial language/hierarchy applied prior to sending to the denial team
          OTHER DUTIES:
          • Perform other duties, projects or actions as assigned
          • May be required to cover occasional month weekend and or holiday to maintain our required TAT.
          • Able to cover multiple IPAs to assist as needed.
          • Participate in staff meetings, provide suggestions/feedback
          • Cross trained in a variety of UM functions
          • Team player
          • Work with the denial department to ensure appropriate us of the denial language is applied.
            • Active Unrestricted Current California Registered Nurse or Licensed Vocational Nurse license.
            • The employee to reside in California
            • A minimum of two year's health plan, IPA or MSO experience in management.
            • Experience with clinical issues, clinical guidelines, case management, & managed care.
            • Working knowledge of ICE, DHS, DMHC, NCQA, and CMS standards.
            • Excellent analytical critical reasoning and interpersonal communication skill.
            • Good presentation, verbal and written communication skills and ability to collaborate with co-workers, senior leadership and other management.
            • Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
            • Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
            • Must possess the ability to educate and train staff members and other departments as needed
            • Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
            • Must be ethical and possess the ability to remain impartial and objective.
            • Proficient with Microsoft applications', EZCAP, and crystal reports.
            • Personal & Professional Qualities
              • Punctuality, Creativity, Self-motivation
              • Professional appearance and conduct.
              • Conceptual and "big picture" understanding
              • Able to function independently under time constraints
              • Willing to learn and develop new responsibilities and skills.
              • Good organization, critical thinking and problem solving skills.
              • Must be detail-oriented and able to work autonomously but also as a team member
              • Should have strong communication and customer service skills and respect for confidentiality.

Keywords: Network Medical Management Inc, Monterey Park , UM REVIEW NURSE, LVN, Healthcare , Monterey Park, California

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