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Department:  Nursing
Status:  Full Time
Shift:  1st

The Utilization Management (UM) Nurse is responsible for medical necessity review of incoming referrals, Pre-Service, Retro and Post Claims requests. The UM Nurse will review the submitted request and supporting clinical records for Medical Necessity, Clinical Appropriateness, Standards of Care, Experimental and Investigation and the efficient use of health care services consistent with the Federal, State, Health Plan, Accreditation (URAC, NCQA) and national evidence based clinical criteria/guidelines. The UM Nurse will also determine and consider the most cost-effective quality care in the most appropriate setting.  Reviews will be conducted in a timely manner taking into consideration patient care needs, medical urgency and any applicable Federal, State, Health Plan, Accreditation (URAC, NCQA) turn-around time standards.  Will gather pertinent clinical information before making any determinations and comply with out-reach attempts requirements by the Federal, State, Health Plan and Accreditation (URAC, NCQA) standards as applicable. Will comply with timely documentation and member/provider notification standards in line with any Federal, State, Health Plan, and Accreditation guidelines.


Essential Functions:

  • Conduct medical necessity reviews on incoming Pre-Service/Prior-Authorization, Retrospective and Post Claims reviews on Urgent/Expedited and Routine/Standard referrals/authorizations requests in compliance with any Federal, State, Health Plan, Accreditation (URAC, NCQA) requirements.
  • Request the pertinent clinical records to make a sound determination and follows the standard out-reach attempts (3 attempts on different dates and times) and methods (at least two methods, oral or written) set by the Federal, State, Health Plan and Accreditation standards.
  • Document on the Medical Management System in a timely manner, all supporting clinical information, outreach attempts (if applicable) and criteria used to make a determination.
  • Taking into account the member’s eligibility, benefits and network before making any determination.
  • Gather and submit all requests that do not meet medical necessity criteria/guidelines to the UM Medical Director for second level review and determination.
  • Ensure that all notification (oral or written) standards are met are in line with the Federal, State, Health Plan, and Accreditation standards. Member letter should be in lay prudent person’s language (6th grade level) and would include the necessary appeal rights on denial notifications.
  • Identify and refer any potential quality of care or care delay issues to both the Medical Director and the Quality department as appropriate.
  • Monitor, track, and report any trending inappropriate referrals/authorization to the UM Medical Director and/or the UM Manager.
  • Ensure that all Out of Network (OON) services are steered to the network providers if access to care is available. Any OON request should be reviewed and approved by the UM Medical Director and has corresponding Letter of Agreement (LOA) or Special Pricing Agreement (SPA) in place.
  • Appropriately utilizes contracted providers, vendors, facilities based upon contractual requirements noted on the Division of Financial Responsibility and risk arrangements with the members Health Plan.
  • Maintains an average daily review volume of approx. 18 to 25 touches per day.
  • Collaborate and coordinate with the Network team on LOA/SPA negotiations on financial arrangements when non-contracted providers or services are needed.
  • Works with the Member Services Team for resolving any clinical concerns/complaints by the members.
  • Discuss with the members or providers as necessary any referral/authorization related concerns.
  • Demonstrate appropriate use, interpretation and documentation of clinical criteria in the review process such as National Coverage Determination (NCD), Local Coverage Articles (LCA), Local Coverage Determination (LCD), California Coverage Determinations, Health Plan Medical Coverage Policies, MCG, NCCN etc.
  • Identify and report to the UM Manager or the necessary department any new member transition of care needs, subrogation or third party liability, other insurance information or coordination of benefits (COB) for handling per department policy.
  • Appropriately identify and refer patients to Internal MSO programs such as high-risk care management, disease management programs, etc.
  • Other duties as assigned.


Job Qualifications

Education, Training and Experience


  • Registered Nurse (RN) in the State of California
  • At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or  Risk Based MSO setting.
  • Computer experience in MS Word, Excel and MS Office Programs
  • Experience with Medicare/Medicare Advantage Plans, Commercial Plans,  HMO, and/or Medi-Cal/ACA standards


  • 2 to 3 years of UM review Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
  • Bachelor’s degree in a health care related field

Skills or Other Qualifications


  • Proven and effective problem-solving, critical thinking, and decision-making skills.
  • Collaborative, team-oriented approach to decision-making.

License and Certification

Required: RN

Preferred: N/A

Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Nursing, Medical, Patient Care, Medicare, Registered Nurse, Healthcare

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