The Utilization Management Department is a core function of Serra Community Medical Clinic that involves the evaluation of medical necessity for healthcare services with evidence-based criteria and guidelines to ensure members receive the highest quality of care in the most appropriate setting. The Utilization Management Nurse Reviewer (UR) is responsible for performing medical/surgical reviews. This includes certification reviews, continued stay reviews, patient information and education, individual case management referral, and processing of appeals and denials with Health Care Advisers. This is a facilitator role in the discharge planning and referrals process, and screening for Case Management, where prior experience in hospital, residential, and outpatient behavioral healthcare systems is critical. This position may also include participating in team functions such as committees, QA team evaluations, and preceptorship.

The UM Nurse is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and be respectful and courteous in the conduct of this position.

Job Requirements

1. Current, unrestricted state LVN license required.

2. 1-3 years experience in a hospital setting, acute care, direct care experience preferred experience as case manager, care coordinator, concurrent review nurse, utilization review nurse, or discharge planner preferred.

3. Computer proficiency including the ability to type and talk at the same time, and navigating an Apple Mac environment required.

4. Prior experience with EMRs, case management, utilization/concurrent review, prior authorization, care coordination, & discharge planning software tools a plus.

5. Working knowledge of Milliman and Apollo guidelines.

6. Basic knowledge of health care contracts, benefit eligibility requirements, hospital structure and payment systems preferred.

7. Strong organizational skills, the ability to multitask in a constantly changing environment.

8. Ability to work autonomously yet be a part of the medical management team.

9. Effective interpersonal skills.

10. Bilingual: SPANISH speaking preferred.

Job Type: Full-time

Required experience:

• Nursing: 1 year
• Hospital Setting: 1 year

Required License:

• Registered Nurse (RN)
• Licensed Vocational Nurse

Job Type: Full-time

Pay: $30.00 - $35.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Employee discount
• Health insurance
• Paid time off
• Vision insurance

Experience:

• Case management: 1 year (Preferred)

Language:

• Spanish (Required)

License/Certification:

• LVN (Preferred)

Work Location: In person