UM Review Nurse

Astrana Health Orange, CA 92868, US

$34 - $47 / hour

UM Review Nurse

Department: HS - UM

Employment Type: Full Time

Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Reporting To: Brenda Fresnares

Compensation: $34.00 - $47.00 / hour

Description

Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans.

This is a remote position for CA-licensed nurses. Candidates must live in California.

We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting.

Our Values:

Put Patients First
Empower Entrepreneurial Provider and Care Teams
Operate with Integrity & Excellence
Be Innovative
Work As One Team

What You'll Do

Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment
Refer cases to Medical Directors as needed/appropriate
Maintain knowledge of state and federal regulations and accreditation standards
Comply with internal policies and procedures
Perform any other job duties as requested

Qualifications

Active and unrestricted LVN license in CA.
At least 1 years of outpatient UM experience
Experience with Microsoft applications such as Word, Excel, and Outlook

You’ll be Great for this Role If:

At least two (2) years of health plan, IPA or MSO experience
Strong interpersonal skills
Ability to collaborate with co-workers, senior leadership, and other management
Experience educating and training staff

Environmental Job Requirements and Working Conditions

This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid.
The schedule is M-F 8 A - 5 P.
The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.

Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Share this job

Related Jobs

UM Review Nurse

Astrana Health Monterey Park, CA

$34 - $47 / hour

UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Phillip Vasquez Compensation: $34.00 - $47.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a remote position for CA-licensed nurses. Candidates must live in California. We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. At least 1 years of outpatient UM experience Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: At least two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Utilization Review

Per Diem

3 days ago

Case Manager Utilization RN-Per Diem Day

Kaiser Permanente Riverside, CA

Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.

Utilization Review

4 days ago

Case Management Utilization RN, 40/hr Day

Kaiser Permanente Irwindale, CA

Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs. Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.

Utilization Review

1 week ago

ED Case Management Utilization RN, 32/hr Night

Kaiser Permanente Irwindale, CA

Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs. Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.

Labor and Delivery

9 hours ago

Specialty Unit Staff RN - Hospital Labor & Delivery

Kaiser Permanente CA

Job Summary: As the leader of the health care team, provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. Demonstrates performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization. Remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats co-workers, patients, families, and all members of the health care team with dignity and respect. Essential Responsibilities: The Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Upholds Kaiser Permanente's Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately and demonstrates appropriate accountability. Understands own and team members scope of practice and escalates issues as appropriate. Demonstrates professional, supportive behavior. Champions new ideas. Leads and directs others through the change process. Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes. Participates in problem identification and resolution. Mentors, orients, and coaches' others in unit specific operations and patient care activities Shares responsibility and authority with subordinates and holds him/her accountable for performance. Demonstrates ability to problem solve with other departments in order to assist member problem resolution. Prioritizes, delegates, and supervises work assignments appropriately to ensure completion of patient care activities. Complies with regulatory requirements, policies, procedures, and standards of practice. Nursing Process: Develops and/or contributes to the individualized plan of care that reflects assessment, planning, implementing, and evaluating the outcomes of that plan. Ensures plan shows multidisciplinary planning, consultation, and education. Ensures plan is reflective of admission or outpatient database, on-going findings, age-appropriate care, culturally specific needs, and appropriate acuity. Ensures plan is discussed with patient, family/significant others, and completed in a timely manner. Monitors the patients progress based on the plan. Revises plan on ongoing basis based on patient condition and evaluation of progress. Ensures care meets standards of practice. Ensures effective development and completion of discharge plan including discharge barriers and patient/family education. Ensures that patient clearly understands discharge instructions. In outpatient, identify barriers and needs for patient/family education that will facilitate the outpatient medical management plan. Ensures patient safety related but not limited to, medications and procedures utilizing the five rights; patient falls; decubitus prevention and prevention of nosocomial infections. Ensures optimal pain control and patient comfort; identifies and discusses patient anxieties, fears or concerns regarding patient condition, treatment or discharge. Ensures that patient understands medication purpose, side effects, and administration instructions in the hospital as well as at the time of discharge . Documentation: Charting is accurate, legible, dated, and timed. Documentation reflects nursing process and interventions and evaluations taken. Utilizes computer systems effectively and efficiently for optimal patient care. Clinical Outcomes: Discusses patient findings and progress toward outcomes with physicians and other members of the health care team. Demonstrates competencies during the probationary period and ongoing completion by departmental competency validation. Make comprehensive nursing decisions based on interpretation of data, assessments, and evaluations of patient outcomes. Participates in departmental performance improvement activities, i.e., planning, measuring/monitoring, assessing, and improving. Workplace Safety: Adherence to LMP Workplace Safety principles and practices. Applies standard precautions; maintains a safe environment for self and others Patient Care Experience: Practices customer service standards as defined by the Service Area, Medical Center, and specified department. Promptly answers call lights, alarms, and patient requests. Makes appropriate referrals and facilitates the customers' ability to utilize resources. Maintains and protects patient confidentiality Ensures clean, orderly, and functional work environment. Treats all families of patients with courtesy, respect, kindness and compassion. Provides an optimal patient care experience by actively listening to the needs of patients and family members and taking responsibility for meeting those identified needs. Gives patients information in a way they can understand and ensures comprehension. Provides a patient care experience that exceeds members expectations. Team Commitment: Viewed by others to be an effective team member who is flexible, cooperative, and willing to assist others. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Takes accountability for own actions and accepts constructive criticism. Acts as a resource, preceptor, and mentor to new employees, registry, students, and other team members. Attends all mandatory meetings, in-services and staff meetings as required, actively participates in other departmental professional development. (Requirement may vary for per diem staff). Participates with the assessment of current and future unit learning needs and development of an annual education plan. Keeps self-informed of activities on the unit and makes recommendations for change. Adheres to Attendance Program. Reports to assigned area promptly, being present and available for report at beginning of assigned shift. Supports a collaborative Labor-Management Partnership environment through unit-based teams. Fiscal Responsibility Organizes work to minimize the use of overtime. Identifies and assists in systems improvement that needs simplification or correction. Utilizes payroll and non-payroll resources to their maximum potential.