Utilization Management RN Superviso... Job at Meritage Medical Network
Job Description
Location: Petaluma
Employment Status: Full-Time
General Summary:
The UM RN Supervisor designation carries additional duties and responsibilities that overlay a senior lead staff member’s regular job responsibilities in a functional area when it’s determined that the area needs greater on-site supervision of staff and operational oversight then is previously been provided to a work team. This position is responsible for analyzing clinical information submitted by medical providers by evaluating the medical necessity, appropriateness and efficiency of the medical services, procedures and facilities use for commercial and Medicare members. The supervisor serves as an expert daily resource to assigned department staff and other internal and external customers, vendors and company business partners. The supervisor is the established “go to” person to assist others with questions, guidance, training, and support with technical, administrative and customer service aspects of the department. Evaluations are completed using evidence-based guidelines created for non-physician clinicians establishing medical necessity. These duties may include assignments to all venues requiring utilization management such as pre-authorization for inpatient and outpatient services, concurrent inpatient and observation hospital stays, Skilled Nursing Facility (SNF) stays, ambulatory services and other services as required. This job may coordinate utilization management and case management activities. The Utilization Management nurse is knowledgeable about the CA Nurse Practice Act, NCQA, MCG (Milliman Care Guidelines), the Center for Medicare and Medicaid, DMHC and timeliness rules and pertinent state and federal regulations.
Salary Range: $113,589 – $135,171 per year
Specific Duties: A supervisor engages in leadership and first line management responsibilities on average, greater than 50% of the time.
- Review routine and urgent requests for service authorization on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
- Prepares and presents cases for UM Medical Director review in a concise, objective and organized manner.
- Educates and supports members in accessing care using their HMO and Medicare Advantage benefits as indicated.
- Identifies and refers patients to disease management, wellness programs and community resources whenever relevant.
- Utilizes the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
- Additional supervisory duties according to Supervisor Role Designation.
- Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
- Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
Job Requirements
- Current and unrestricted license from the California Board of Nursing.
- Completion of Diploma or Associates Degree in Nursing.
- Bachelor’s Degree in the Science of Nursing preferred.
- Minimum three years of clinical experience.
- Minimum one year in a managed care or health plan environment.
Knowledge, Skills, and Competencies
- Ability to understand and facilitate communication among team members, patients, families, physicians and medical office staff.
- Ability to communicate effectively with contracted health plans and meet required turnaround times.
- Excellent clinical judgment, critical thinking skills and independent problem resolution.
- Knowledge of managed care principles, HMO and Risk contracting arrangements.
- Ability to organize and prioritize workload.
- Proficient typing skills with competency in working with Microsoft Word, Excel, Outlook, varied EMR platforms. Prior experience with Health Care Management/authorization software preferred.
- Excellent telephonic customer service skills.
- Flexibility to learn and work in various RN assignment within the department.
- Ability to work with and provide sensitivity to a variety of culturally diverse communities.
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