Administrative

Utilization Managment Review Nurse

Lakeside Community Healthcare is seeking Utilization Management Review Nurses who are familiar with utilization review processes and InterQual Outpatient Criteria. The preferred candidate will be an RN, although LVNs with appropriate expereince will be considered.

The Utilization Review Nurse will review provider requests for services against established health plan benefits, standard review criteria, and referring cases not meeting criteria to the appropriate medical director for review. The Utilization Review Nurse will evaluate the options and services required to meet the members’ health and psycho-social services needs, in support and collaboration with patients’ diagnosis (or diagnoses) 

The goal of Utilization Review is to assist the provider in identifying appropriate options for the level of care that will assist the patient in achieving optimum stability of health status within their defined disease state and/or diagnosis. Provider General Responsibilities Include:

  • Manage assigned workload within established performance standards.
  • Support and lead the Prior Authorization Coordinators to manage prior authorizations in a most effective and efficient manner.
  • Establish and maintain positive relationships with providers, patients and caregivers through telephonic and / or onsite visits.
  • Establish positive relationships with treating physicians and other health care providers through collaborative problem solving.
  • Perform Utilization Review - pre-authorization, review as needed for outpatient services and/or predetermination reviews for services or levels of care requiring authorization according to health plan, state, and federal regulations.
  • Maintain open communication flow with Vital Care Team (complex cases) or Social Services staff to facilitate smooth transition and follow-ups care as needed.
  • Maintain all required documentation in the information data systems in a timely manner.
  • Participate in case conferences, clinical in-services and other educational opportunities.
  • Serve as a resource for recognized areas of expertise.
  • Perform other tasks as assigned by supervisor/manager/Director.

Qualifications:

  • Requires a current California RN or LVN license.
  • Must have at least two years of prior Utilization Management experience.




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Medical Phone Receptionists

Ideal candidate will be an exceptional communicator and team player, be well organized, detail oriented, and possess excellent telephone and customer service skills. Requires medical terminology and at least 1 year medical front office experience working in a doctor's office or healthcare setting.

Please submit your CV to: hr@lakesidecommunityhealthcare.com or fax to 818 549-0526

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