Utilization Management Nurse, Lead

Role Overview

The Utilization Management Nurse Lead is responsible for reviewing requests for inpatient and prior authorization services for all plan members. Works in collaboration with UM leaders and providers to ensure timely processing of referrals to provide the highest quality medical outcomes at the appropriate level of care.

What You Will Do

Reviews reporting to assign tasks to UM Nurses for completion of time sensitive items, works closely as a liaison between management and the team, participates in department quality audits, and effectively communicates with the Utilization Management leadership team.

Why It Might Be a Fit

This role requires a strong clinical background, leadership experience, and excellent communication skills. The ideal candidate will be able to prioritize multiple tasks, solve complex problems, and work in a fast-paced environment.

Requirements

• Minimum of 3 consecutive years of related experience in concurrent review and/or prior authorization at managed care organization
• Minimum 2 years of experience using MCG
• Successful completion of an accredited Licensed Vocational Nursing or Registered Nursing Program
• Knowledge of Medicare Managed Care Manuals and CMS regulatory requirements
• Ability to communicate positively, professionally and effectively with others
• Effective written and oral communication skills
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving
• Problem-Solving Skills: Effective problem solving, organizational and time management skills
• Report Analysis Skills: Comprehend and analyze statistical reports
• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact)

Benefits

• Pay range: $85,696.00 - $128,543.00
• Reimbursement for obtaining LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas