Location: Los Angeles, CA

Schedule: Full Time / Hours between 8am & 5pm.

Pay: $33 - $46  - Depending on Experience

Job Type: Temporary Assignment

Job Summary:

The LVN Utilization Management Nurse (UM Nurse) will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines. Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency with coverage guidelines. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

Key Responsibilities:

1. Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan

 2. Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective

 3. Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidencebased criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria. 

4. Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making

 5. Maintains up to date knowledge of rules and regulations governing utilization management processes; 

6. Input data into the Medical Management system to ensure timeliness of referral processing.

 7. Verifies member benefits and eligibility upon receipt of the treatment authorization request. 

8. Ensure timelyprovider and member oral and written notification of referral decisions.

 9. Coordinates with Medical Director or referral specialists for timely referralprocessing 10. Facilitates LOA processing by sending request to Provider Contracting for non-contracted providers or facilities, when applicable 

11. Facilitates LOA processing with the Health Plan for non-contracted facilities 

12. May be responsible for daily concurrent review, retro reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based criteria. 

13. Develops a positive working relationship with internal and external customers

 14. Perform additional duties as assigned.

Work Environment:

1. Works in an office environment, climate controlled through air conditioning.

Required Skills and Abilities:

1. Uses computer and computer system (including hardware and software) to perform necessary functions. 

2. Communicates effectively in writing as for the needs of the audience. 

3. Demonstrates excellent interpersonal skills. 

4. Maintains dedicated attention to detail.

 5. Analyzes and interprets reports and data for management purposes.

 6. Demonstrate knowledge of DOFRs and delegation agreements 

7. Adheres to the Altamed Heath services HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.

 8. Knowledge of pre-authorizations and reimbursement regulations pertaining to Medicare, Medi-Cal, Commercial, CCS and other government programs