UM Nurse Manager - Remote / TelecommuteCynet Systems • Costa Mesa, CA
UM Nurse Manager - Remote / Telecommute
Cynet Systems • Costa Mesa, CA
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Job Description:
Pay Range: $50.92hr - $53.92hr
Job Description:
Pay Range: $50.92hr - $53.92hr
- The UM Nurse Manager is responsible for leading and overseeing Utilization Management activities to ensure compliance with federal, state, health plan, and accreditation requirements while supporting high-quality, cost-effective care delivery.
- Ensure the UM team is properly trained to conduct medical necessity reviews for pre-service/prior authorization, retrospective, and post-claims reviews for urgent and routine requests.
- Ensure compliance with federal, state, health plan, and accreditation requirements including URAC and NCQA.
- Maintain staff accountability through performance evaluations, reporting, observation, and annual reviews.
- Ensure staff meet performance goals while adhering to internal and external policies, procedures, and guidelines.
- Ensure timely and accurate documentation of clinical information, outreach attempts, and criteria used for determinations in the medical management system.
- Collaborate with providers, facilities, medical directors, care coordinators, members, and caregivers to meet members’ healthcare needs.
- Support continuity of care through early discharge planning and collaboration with hospital discharge planners and case managers.
- Monitor, track, and report trends related to inappropriate referrals or authorizations to leadership.
- Ensure appropriate network provider utilization and manage out-of-network requests in coordination with clinic operations.
- Identify and manage high-risk members, including those at risk for readmission or with complex medical and psychosocial needs.
- Collaborate with case management to coordinate post-discharge care, follow-up appointments, medications, and outpatient services.
- Serve as a subject matter expert in the application and documentation of clinical criteria including NCD, LCD, LCA, MCG, NCCN, and health plan coverage policies.
- Contribute to cost containment initiatives while maintaining high-quality care delivery.
- Apply process improvement principles and methodologies to support operational efficiency.
- Participate in UM committee meetings and health plan audits.
- Perform other duties as assigned.
- Minimum of 3 to 5 years of nursing management experience in a medical group, hospital, health plan, or risk-based MSO environment.
- Minimum of 5 to 10 years of overall nursing experience in a medical group, hospital, health plan, or risk-based MSO setting.
- Experience with Medicare, Medicare Advantage, Commercial, HMO, Medi-Cal, and ACA plans.
- Strong problem-solving, critical thinking, and decision-making skills.
- Collaborative and team-oriented approach to leadership.
- Proficiency in Microsoft Word, Excel, and other MS Office applications.
- Bachelor’s degree in a healthcare-related field is preferred.
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UM Nurse Manager Remote Telecommute • Costa Mesa, CA
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