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Utilization Mgmt Nurse

Company: Loma Linda University Health
Location: San Bernardino
Posted on: November 21, 2022

Job Description:

Shared Services: Risk Management (Full-Time, Day Shift) -

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.

The Utilization Management Nurse is responsible for coordinating the pre-authorization, concurrent review, retro clinical review and utilization management process of the Health Plan members. Negotiates discounted rates for single case agreements for non-preferred providers on urgent, emergent and concurrent cases. Negotiates with contracted providers for pricing and contract terms. Establishes policies, procedures and protocols through research, development, implementation and monitoring of criteria for inpatient, outpatient procedures, tests, durable medical equipment (DME), etc. For Health Plan benefit determination. Participates as clinical advisor for Health Plan Level 1 Appeal Committees. Performs other duties as needed.

Associate's Degree in Nursing required. Bachelor's Degree Preferred. Minimum of two years of Acute Care Hospital experience required. Minimum total of five years nursing experience required: this would include preferably a broad spectrum of both hospital nursing as well as other nursing. Minimum three years hospital utilization review or case management experience required. Active California Registered Nurse (RN) license required. Certified Professional in Healthcare Management (CPHM), Certified Professional Utilization Review (CPUR) or Certified Professional Utilization Management (CPUM) preferred.

Appropriate levels of care, Utilization Review (UR), Utilization Management (UM), Case Management (CM), claims familiarity, clinical pathways, billing and coding regulations. Must be able to type 30-40 wpm with accuracy, operate 10-key calculator and be proficient in basic computer functions. Ability to analyze and interpret data; judge and act on analysis of data; apply mathematics to manipulate/analyze data; analyze and solve specific problems; Able to read; write and speak with professional quality; use computer and software programs necessary to the position, e.g., Word, Excel, Power Point, Access; operate/troubleshoot basic office equipment required for the position. Able to relate and communicate positively, effectively, and professionally with others; provide leadership; be assertive and consistent in enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently; perform basic math and statistical functions; manage multiple assignments; compose written material; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.

Additional Information

  • Organization: Loma Linda Unv Shared Services

  • Employee Status: Regular

  • Schedule: Full-time

  • Shift: Day Job

  • Hours Description: 80 hours per pay period

  • Days of Week: Monday, Tuesday, Wednesday, Thursday, Friday

  • Monday Hours: 8-5

  • Tuesday Hours: 8-5

  • Wednesday Hours: 8-5

  • Thursday Hours: 8-5

  • Friday Hours: 8-2

  • Sunday Hours: na

Keywords: Loma Linda University Health, San Bernardino , Utilization Mgmt Nurse, Other , San Bernardino, California

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