Nurse Specialist RN II
Los Angeles, CA
1 Months Contract with our Client
Solugenix is hiring a "Nurse Specialist RN II" for one of the premier providers of health insurance in the Los Angeles County area.
The Utilization Management Nurse Specialist RN II will facilitate, coordinate and approve of medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsideration's based on the referral determination status. Generates approval, modifications and denials communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Works with the UM Manager and Physician Adviser on case reviews for pre-service, concurrent post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes.
- Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
- Excellent customer service will be key to the success of this role and the CAN project Utilizes medical knowledge and experience to facilitate consensus building and development of satisfactory outcomes using persuasion skills
- Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM
- Licenses/Certifications Required.
- Registered Nurse (RN) - Active, current and unrestricted California License.
- Active & Current Driver's License, with a clean record and Auto Insurance Required.
- Certified Case Manager (CCM).
- Provides the primary clinical point of contact for the Community Access Network FRC in their assigned community. Ensures Management goals are met, and in a manner consistent with enhancing positive business growth. Functions as the clinical SME for all MSO-level activities. Performs prospective, concurrent, post-service and retrospective claims medical review processes.
- Identifies cases needing Physician Advisor (PA) review or input. Presents cases to PA for potential review or determinations when needed. Performs telephonic and/or on site admission and concurrent review, and collaborates with on site staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan.
- Generates appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.
- Identifies and initiates referrals for appropriate members to the various programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH).
- May be out of the office at least 50% of the workday, driving to various locations, which may include but are not limited to: local acute care facilities and SNFs, physician offices, member homes, and other locations where members may be present.
About The Client
Our client is one of the premier providers of health insurance in the Los Angeles County area.
For over 50 years, Solugenix has been a global technology development and services firm with locations in California, Arizona, India and the Dominican Republic. As a pioneer in [ENTER RELEVANT SPECIALTY], we’ve partnered with some of the biggest global corporations across many industries. Our history was built on a foundation of partnerships with global brands like McDonald’s, Microsoft, CIT Group, Johnson & Johnson, Herbalife, Sony Pictures Entertainment, and many others who look to Solugenix to be their trusted partner in providing professional staffing, non-IT and IT solutions.
We live our core values in everything that we do, starting with “doing the right thing” for our employees/contractors and “committing to client success”. This is a big part of how we continue to make lists like “2019 Forbes Small Giants”. We also forge strategic partnerships with vendors and corp-to-corp candidates (C2C) that share our core values and encourage you to partner with us.
In addition to generating ground-breaking, industry-defining solutions for our clients and our own projects, we partner with clients with whom we share core values and a common professional culture to help them find talent for their valuable opportunities. At Solugenix, we invest in the personal development and growth of every individual. While this is a position with one of our esteemed clients, Solugenix will continue to invest in your personal growth and development, providing you with a successful career as well as ensuring client success