SCOPE OF ROLE
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 member's receive 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 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 transition of care teams, when applicable.
Meet or exceed productivity targets set forth
Serve as a resource to non-clinical team members when applicable
Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
Associate's degree in Nursing, preferred
Minimum 2 years of experience in medical management clinical functions.
Working knowledge of MCG, InterQual, and NCQA standards
LICENSURES AND CERTIFICATIONS
Active and Unrestricted License as a Licensed Vocational Nurse (LVN)
Certification Managed Care Nursing (CMCN) preferred
PROFESSIONAL
COMPETENCIES
High level of critical thinking and problem-solving skills
Strong work ethic and overall positive attitude
Effective communication skills including verbal and written
Ability to manage time effectively, understand directions, and work independently in a fast-paced environment
Demonstrated flexibility, organization, and self-motivation
Highly adaptable to change
For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $26.31-$39.46 Hourly.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.
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