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Utilization Management Reviewer, RN

Job Title: Utilization Management Reviewer, RN

Job Category: Nursing
Division: Torrance Health IPA
Position Type: Full time
Shift Length: TBD
Location: Torrance, CA
Resumes go to:

Under the direction of the Utilization Management Manager and the Director of Medical Management, the Utilization Management Reviewer, RN evaluates medical necessity, appropriateness, and efficiency of medical services for THIPA members while following insurance guidelines. The Utilization Management Reviewer, RN works closely with physicians, hospitals, and health plans along with internal departments concerning utilization review.

Primary Duties and Responsibilities:

  1. Following insurance guidelines, evaluates the necessity, appropriateness, and efficiency of medical services and procedures provided to THIPA members
  2. Coordinates cost effective care supported by clinical practice guidelines
  3. Accurately and comprehensively documents UM decisions based on the standards of practice and current THIPA policies
  4. Effectively provides feedback to providers concerning necessary documentation to meet reimbursement requirements
  5. Acts as a resource for medical and ancillary staff in issues relating to the UM department
  6. Telephonically interacts and communicates with multidisciplinary teams, striving for continuity of care for our members
  7. Understands fiscal accountability and its impact on the utilization of resources
  8. Assists with the daily operation of the UM department
  9. Assumes responsibility for in-house referral reviews and urgent authorization requests; responds to incoming "urgent" telephone authorization requests
  10. Acts as a resource for medical and ancillary staff in issues related to the UM department
  11. Identifies effects of under-utilization, as well as over-utilization of services
  12. Uses, protects, and discloses member’s PHI only in accordance with HIPAA standards
  13. Supports department initiatives
  14. Works closely with the Medical Director, Medical Management, and other THIPA departments to foster open interdepartmental communication and avoid duplication of effort
  15. Assists in determining status of non-complex claims for reimbursement
  16. Interfaces with Contracted Health Plans. Assures timely and appropriate responses to health plan inquiries
  17. Demonstrates ability to effectively handle multiple tasks throughout the workday and to appropriately prioritize those tasks
  18. Demonstrates effective problem-solving techniques by resolving complaints and implementing effective solutions

Knowledge, Skills & Experience Required:

  1. Registered Nurse with CA license
  2. Thorough knowledge of utilization management
  3. The ability to establish and maintain professional relationships and communications with a wide variety of people and to work as a team member.
  4. High multi-tasking skills with the ability to set appropriate priorities
  5. Demonstrated high degree of personal integrity, loyalty to the organization, precision, and attention to detail
  6. Contributes ideas for improving efficiency, productivity, and patient satisfaction
  7. Ability to maintain confidentiality of all patient information
  8. Excellent communication skills

Qualified candidates should submit their resume for consideration to