UM REVIEW NURSE, LVN
Company: Network Medical Management Inc
Location: Monterey Park
Posted on: January 12, 2022
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
ESSENTIAL DUTIES AND RESPONSIBILITIES
Comply with UM policies and procedures. Annual review of UM
- Review & screen incoming service referral requests for medical
- 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
- 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
- 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
- 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
- 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
- Experience with clinical issues, clinical guidelines, case
management, & managed care.
- Working knowledge of ICE, DHS, DMHC, NCQA, and CMS
- Excellent analytical critical reasoning and interpersonal
- Good presentation, verbal and written communication skills and
ability to collaborate with co-workers, senior leadership and other
- Proven ability to prioritized and organize
multi-faceted/multiple responsibilities simultaneously in a fast
paced, changing environment while meeting deadlines and turnaround
- 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
- Must be ethical and possess the ability to remain impartial and
- Proficient with Microsoft applications', EZCAP, and crystal
- 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
- Good organization, critical thinking and problem solving
- 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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