Utilization Manager, RN

The Utilization Manager, RN will be collaborating with clinical and non-clinical personnel, providing timely care which complies with generally accepted standards of clinical practice.

This is an On Site Role in Pasadena, CA.

Must be a current RN.

• Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.
• Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.
• Ensure UM team documents on the medical management system are timely, including all supporting clinical information, outreach attempts, and criteria used to make a determination.
• Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services.
• Serves as a subject matter expert on appropriate use, interpretation, and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.
• Conduct inpatient huddles to review inpatient census, including Inpatient CMs and CMO to discuss cases and discuss barriers of discharge planning.
• Conduct Annual IRR Reviews for clinical staff by using case studies via MCG Learning Module.
• Conduct Annual IRR Reviews for non-clinical staff by administering quiz.
• Prepare and participate in internal and external audits. Health plan, CMS, NCQA, DHCS, state or federal exchange.
• Develop and revise UM program, workplans and policies and procedures.

Seniority level

Mid-Senior level

Employment type

Full-time

Job function

Other

Industries

Insurance