UM Nurse - APN Consulting Inc

Monmouth Junction, CA 08852

About the Job

Role Description

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.
Role and Responsibilities

Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
Meet or exceed productivity targets set forth
Serve as a resource to non-clinical team members when applicable

Qualifications and Education Requirements

Associate's degree in Nursing, preferred
Minimum 2 years of experience in medical management clinical functions.
Working knowledge of MCG, InterQual, and NCQA standards
Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
Certification Managed Care Nursing (CMCN) preferred

Additional Notes

Workdays/Hours: Would like to include evening, weekend and holiday coverage.

Source : APN Consulting Inc