Pre-Service UM RN

Company: Common Spirit
Location: Bakersfield
Posted on: April 23, 2025

Job Description:

Overview

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

One Community. One Mission. One California

Responsibilities

* This position is remote with a clear and current CA RN license. Preference is for candidate to reside within California.
* Please note: This position will be expected to work rotating holidays and weekends.

Position Summary:

The Utilization Management RN is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices to review medical records, authorize requested services and prepare cases for physician review based on medical necessity. The position partners with both the Pre-Service and In-Patient Utilization Management teams. Ensures to monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity and cost effectiveness.

Responsibilities may include:

* Reviews designated requests for referral authorizations either proactively, concurrently or retroactively. Gathering all information needed to make a determination and/or coordinate with the Medical Director as needed.
* Ensure compliance with turnaround times and accuracy standards are met.
* Ensure contracted providers are in place when authorizing.
* Responsible to coordinate with contracting to obtain appropriate contracts as deemed appropriate.
* Identify cases that require additional case management.
* Work with appropriate departments and internal staff to coordinate patient care.
* Promotes quality, cost effective medical care through strict adherence to all utilization management policies and procedures.
* Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards.
* Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member's condition and request.
* Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial.
* Provides relevant clinical information to the request and the criteria used for decision-making.
* Ensures that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied.
* Evaluates out-of-network and tertiary denials for accessibility within the network.
* Performs a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines.
* Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination.
* Escalates non-compliant cases to UM compliance and consistently reports on denial activities.
* Collaborates with the Delegation Oversight Department and compliance for continued quality improvement efforts for adverse determinations.
* Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution.

Qualifications

Minimum Qualifications:

* Minimum of 3 years' recent clinical experience required.
* Graduate of an accredited RN Program.
* Clear and current CA Registered Nurse (RN) license.
* Knowledge of nursing theory and ability to apply or modify as appropriate.
* Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits.
* Knowledge of legal and ethical considerations related to patient information, PHI and HIPAA regulations.

Preferred Qualifications:

* Prior Utilization Management (UM) experience preferred.
* Bachelor's degree in Nursing preferred

Keywords: Common Spirit, Bakersfield , Pre-Service UM RN, Healthcare , Bakersfield, California