UM Review Nurse
Location: Monterey Park
Posted on: June 13, 2022
SUMMARY To 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. ESSENTIAL DUTIES AND RESPONSIBILITIES Comply with UM
policies and procedures. Annual review of UM policies.
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
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 when
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
Work with the denial department to ensure appropriate us of the
denial language is applied. QUALIFICATIONS:
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 standards.
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 time
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 skills.
Good organization, critical thinking and problem solving
Must be detail-oriented and able to work autonomously but also as a
Should have strong communication and customer service skills and
respect for confidentiality. #HPIND
Keywords: ApolloMed, Monterey Park , UM Review Nurse, Healthcare , Monterey Park, California
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