Central Coast Salary Range: $84,877 – $123,072 Annually
Job Summary
The Utilization Management (UM) RN for the D-SNP program plays a critical role in ensuring members receive timely, medically necessary, and cost-effective care. This position is responsible for:
Conduct Clinical Reviews and Authorization Determinations
Perform clinical reviews, prior authorization decisions, and concurrent reviews for inpatient and outpatient services using evidence-based criteria and regulatory guidelines for dual-eligible members.
Coordinate Care and Support Member Outcomes
Collaborate with care managers, providers, and interdisciplinary teams to ensure timely, medically necessary, and cost-effective care, helping to reduce barriers and improve health outcomes for D-SNP members.
Ensure Regulatory Compliance and Quality Standards
Apply appropriate regulatory guidelines and maintain compliance with both Medicare and Medi-Cal requirements in all utilization management activities.
Support Education and Continuous Improvement
Contribute to process improvement initiatives, compliance efforts, and the development of educational materials for providers and members.
Duties and Responsibilities
1. Conduct Clinical Reviews and Authorization Determinations
Review and evaluate requests for inpatient, outpatient, and ancillary services for D-SNP members, ensuring medical necessity, cost-effectiveness, and alignment with the D-SNP Model of Care using evidence-based criteria such as MCG guidelines, Medi-Cal criteria, and CenCal Health policies.
Perform timely and accurate utilization management reviews, including:
Prospective (pre-service) prior authorization
Concurrent reviews in acute, subacute, skilled nursing, and long-term care settings
Retrospective (post-service) reviews
Selective claims reviews and other case types as indicated
Compose accurate and timely draft notices of action, non-coverage, and other regulatory notifications in accordance with Medicare Advantage and Medi-Cal requirements.
Maintain comprehensive documentation in care management systems, including case review summaries and proper citation of clinical sources.
Manage denials and appeals, coordinating with providers, members, and compliance teams to ensure proper resolution.
2. Coordinate Care and Support Member Outcomes
Collaborate daily with physicians, interdisciplinary care teams, and other providers to assess treatment plans and address complex medical, functional, cognitive, and psychosocial needs of D-SNP members.
Apply utilization review principles and evidence-based guidelines to promote care continuity across settings, including skilled nursing and long-term care.
Participate in interdisciplinary team rounds, care transition planning, and post-discharge coordination to reduce avoidable hospitalizations and support member well-being.
Coordinate with Pharmacy, Quality Improvement, Health Programs, and other internal departments to ensure integrated care and appropriate use of resources.
3. Ensure Regulatory Compliance and Quality Standards
Serve as a liaison to providers and internal teams, promoting understanding of utilization management processes, operational standards, and D-SNP-specific requirements.
Identify and escalate potential quality of care concerns, collaborating with Medical Management leadership and quality teams.
Support data collection, audits, and reporting to meet CMS, DHCS, and internal compliance standards.
Uphold member confidentiality and adhere to HIPAA and other relevant laws and regulations.
Stay informed about current federal, state, and D-SNP program guidelines related to utilization management.
4. Support Education and Continuous Improvement
Educate providers and internal staff on coverage determinations, appeals processes, and alternative treatment options in alignment with D-SNP requirements.
Assist in the development, implementation, and evaluation of quality improvement initiatives and departmental projects aimed at improving D-SNP performance and member outcomes.
Contribute to internal process improvement and workflow optimization within the utilization management program.
Knowledge/Skills/Abilities
Comprehensive Clinical Knowledge: Strong understanding of adult health conditions, chronic disease management, and complex care needs common among D-SNP populations, including functional, cognitive, and psychosocial aspects.
Utilization Management Expertise: Skilled in applying utilization review principles across prospective, concurrent, and retrospective reviews. Proficient with nationally recognized criteria such as MCG guidelines, Medi-Cal, Medicare Advantage regulations, and CenCal Health policies.
Regulatory and Compliance Awareness: In-depth knowledge of Medicare Advantage, Medi-Cal, CMS, DHCS, and other federal/state guidelines governing D-SNP utilization management and documentation standards.
Clinical Decision-Making and Judgment: Ability to accurately assess medical necessity, appropriateness, and cost-effectiveness of inpatient, outpatient, and ancillary services, ensuring alignment with the D-SNP Model of Care.
Strong Communication and Collaboration: Excellent verbal and written communication skills to liaise effectively with physicians, interdisciplinary care teams, providers, members, and internal stakeholders. Capable of educating providers on coverage determinations and appeals.
Documentation and Reporting Skills: Proficient in documenting clinical findings, case reviews, and regulatory notifications in care management systems, ensuring accuracy and timeliness.
Quality Improvement and Problem-Solving: Ability to identify quality of care concerns, participate in interdisciplinary rounds and care transitions, and contribute to quality improvement initiatives that enhance member outcomes.
Appeals and Denials Management: Skilled in managing denials and appeals processes, coordinating with providers, members, and compliance teams for resolution. Work collaboratively with member services.
Analytical and Data Management Skills: Competent in supporting data collection, audits, and reporting to meet regulatory and internal requirements. Detail-oriented in reviewing medical records and utilization data.
Teamwork and Interdepartmental Coordination: Ability to work collaboratively with Pharmacy, Quality Improvement, Health Programs, and other internal teams to promote integrated, member-centered care.
Time Management and Prioritization: Efficiently manages multiple cases and priorities to meet deadlines and operational standards in a dynamic healthcare environment.
Technological Proficiency: Experience with electronic medical records (EMR), utilization management software, and reporting tools.
Ethical and Legal Integrity: Commitment to maintaining member confidentiality and compliance with HIPAA and all applicable laws and regulations.
Education and Experience
Required:
Current, active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years of experience in this nursing role in a managed care setting, hospital, health plan or other equivalent setting.
Minimum of 3 years of clinical nursing experience, preferably in acute care, case management, utilization management, or a related healthcare setting.
Experience working with adult and complex chronic populations, including those in skilled nursing, long-term care, or post-acute settings.
Prior experience with utilization management processes such as prior authorization, concurrent and retrospective reviews, and appeals management strongly preferred.
Familiarity with Medicare Advantage and Medicaid (Medi-Cal)
Demonstrated knowledge of clinical guidelines and evidence-based criteria (e.g., MCG guidelines) for utilization review.
Preferred:
Bachelor of Science in Nursing (BSN)
Certification in case management, utilization, quality, or healthcare management, such as CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, ACM or board certification in an area of specialty.