UM Nurse (Part Time)

Clinicas Del Camino Real - Camarillo, CA

Part-time - Entry Level

Camarillo, CA

Ambulatory Health Care Services

About the position

The UM Nurse position involves conducting clinical reviews for service requests to ensure medical appropriateness and necessity. The role requires strong clinical judgment and the ability to interact with healthcare providers and members to facilitate access to care. The position is divided into two levels: Level 1 for Licensed Vocational Nurses (LVNs) and Level 2 for Registered Nurses (RNs), with increasing responsibilities and expectations for clinical analysis and decision-making.

Responsibilities

• Conduct clinical review for service requests for medical appropriateness and medical necessity using clinical judgment and independent analysis.
• Review, triage, and prioritize authorization requests to meet required turn-around times.
• Expedite access to appropriate care for members with urgent needs using the expedited review process.
• Research member issues and assess needs related to authorization requests.
• Acquire appropriate clinical records and accurately apply coding guidelines.
• Develop determination recommendations and present cases to the Medical Director for potential denial determinations.
• Interact with providers or members to communicate determination outcomes in compliance with regulations.
• Develop and review documentation and correspondence to members and providers reflecting determination outcomes.
• Document all activities as per department practice and recognize potential quality of care concerns.
• Make appropriate referrals to California Children's Services and Tri-Counties Regional Center.
• Identify and refer members who may benefit from care coordination programs.
• Attend meetings or meet with staff as assigned.
• Perform other duties as assigned, including participation in safety programs.

Requirements

• Graduate of an accredited Licensed Vocational nursing program (for Level 1).
• Active, valid, & unrestricted State of California Licensed Vocational Nurse license (for Level 1).
• Understanding of federal and state regulations/requirements, including HIPAA, and/or JCAHO or NCQA criteria.
• Strong analytical and problem-solving skills (preferred).
• Excellent verbal and written communication skills, with a focus on clinical documentation.
• Ability to work independently and as a team player.
• Basic understanding of standardized clinical guidelines/criteria (e.g. MCG, InterQual).
• Strong organizational and time management skills.
• Proficiency in PC-based software programs including MS Word.
• Bilingual (English/Spanish) speaking and writing (preferred for Level 1).
• Graduate of an accredited nursing program (e.g. ASN, ADN, BSN, MSN) for Level 2.
• Active, valid, & unrestricted State of California Registered Nurse license for Level 2.
• Strong analytical and critical thinking skills for complex care coordination opportunities (for Level 2).
• CCM, URAC, or Managed Care Nurse certification (preferred for Level 2).
• Two or more years of experience in a fast-paced insurance or health care setting (preferred for Level 2).

Nice-to-haves

• Bilingual (English/Spanish) speaking and writing (for Level 1).
• CCM, URAC, or Managed Care Nurse certification (for Level 2).
• Varied background in nursing disciplines such as acute inpatient care, home health, outpatient clinic, behavioral health, and ancillary services (for Level 2).