UM Nurse (California License) (Remote)
Posted 1 week ago by 1753177058
Negotiable
Outside
Remote
USA
Summary: The UM Nurse role at NueHealth is a remote position requiring a California nursing license, focused on promoting quality and cost-effective healthcare outcomes. The nurse will facilitate collaboration across settings, review patient records, and provide recommendations without direct patient interaction. The position demands evening, weekend, and holiday coverage as needed, with an emphasis on medical necessity reviews and care coordination. Immediate hiring is anticipated for qualified candidates.
Key Responsibilities:
- Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
- Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
- Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
- Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
- Meet or exceed productivity targets set forth
- Serve as a resource to non-clinical team members when applicable
Key Skills:
- Associate's degree in Nursing, preferred
- Minimum 2 years of experience in medical management clinical functions
- UM experience should be inpatient required
- Familiarity on Medicare and Medicaid and MCG
Salary (Rate): undetermined
City: undetermined
Country: USA
Working Arrangements: remote
IR35 Status: outside IR35
Seniority Level: undetermined
Industry: Other
NueHealth
LinkedIn with photo
Job Title: UM Nurse (California License) Must be licensed in California- Remote Opportunity
Work Hrs: (8am 5pm PDT) would like to include evening, weekend and holiday coverage.
Remote Opportunity
Ready to Hire ASAP.
JD: The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.
This position is not patient facing, they will be reviewing patient records and providing recommendations.
Role and Responsibilities
- Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
- Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
- Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations
- Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
- Meet or exceed productivity targets set forth
- Serve as a resource to non-clinical team members when applicable
Qualifications and Education Requirements
- Associate's degree in Nursing, preferred
- Minimum 2 years of experience in medical management clinical functions.
- UM experience should be inpatient required