UM/Medical Management Clinical Nurse is responsible for working with healthcare providers, pharmacist reviewer, physician reviewers, and medical directors to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to pre and/or retro authorize services, assess medical necessity, out of network services, and appropriateness of treatment setting by applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. The UM/MM Clinical Nurse collaborates with providers and clinical practices/offices (PCP and specialists) to promote the most appropriate, highest quality and effective use of clinical services to ensure quality member outcomes, and to optimize member benefits. The UM/MM Clinical Nurse is expected to meet department performance standards and metrics related to case reviews and including but not limited to investigating and processing medical necessity appeals requests from members and providers, including research of adverse selection cases. This position is also responsible with optimization and integration of member services, network management, provider and member relations, marketing, training/development, resource management, as it may relate to the respective clinical practice(s)/offices they are assigned to. They work collaboratively with the all of the teams under Care Coordination department and assist the management team with special projects, when needed. The position will also be responsible for directing the activities of the Medical Management Coordinator in order to fulfill the business needs and initiatives of the department.
Essential Job Duties:
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
- Effectively and efficiently review prior authorizations and retrospective authorizations, providing updated criteria and necessity, utilizing the appropriate tools and reviewing diagnostics that is and consistent with the members' eligibility, benefits and contract.
- Investigating, processing, and assist with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy.
- Collaboration with clinical teams and practices to ensure synchronization of sub-areas' operations to reach organizational and departmental goals.
- Identify possible adverse selection cases for new members with high cost diagnosis and/or comorbidities.
- Maintaining and updating the appropriate databases and department tools with current information.
- Ensure contract compliance and adherence to DMHC, OHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
- Oversight of database maintenance and accuracy through use of audits.
- Must obtain an overall score of at least 90% with internal case review file audits.
- Assist management with any special projects, as assigned.
- Meet department performance standards and metrics.
- Know and follow the Employee Handbook policies and procedures.
- Maintain patient and provider specific confidentiality so that HIPPAA compliance is observed at all times.
- Give directions in regards to Medical Management Coordinator function and activities to assist them (nurses) of their daily production and performance in order to complete all assigned work by the end of business day.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.