Utilization Management Nurse
Company: Kaiser Permanente
Posted on: June 19, 2022
Performs telephonic medical necessity reviews utilizing established
and evidenced based criteria on all designated pre-certification
requests, as well as targeted outpatient procedures, services and
inpatient admissions. Essential duties include but not limited to
prospective review of outpatient and inpatient admissions and/or
services; concurrent review and discharge planning for all members
admitted to acute, sub-acute and/or skilled nursing facilities;
retrospective review for services not pre-certified and/or
reconsiderations. In collaboration with physician and healthcare
team, facilitate appropriate resource utilization within contracted
and non-contracted facilities. Evaluates eligibility and benefit
information and educates member and/or family, physician and
interdisciplinary healthcare team as to meet the health needs of
the member and minimize out of pocket costs. Identify and refer
appropriate members to case management, disease management, risk
management and quality improvement. Establish relationships and
communicate with members, family, inpatient and outpatient
providers and case managers, community resources, skilled nursing
staff, members service, claims, contracts, benefits, appeals, risk
and quality management.
- Must possess an active professional license to practice in a
state or territory of the United States and practice within scope
of practice that is relevant to the clinical area(s) addressed in
initial clinical review.
- Utilizes established criteria to perform pre-certification
review for all members requiring a procedure or service or with an
admission diagnosis on the targeted review list.
- Obtains clinical data and determines medical necessity for
pre-admission, admission, concurrent and retrospective review for
contracted and non-contracted facilities utilizing established
guidelines and/or criteria.
- Independently identifies high risk patients in need of
post-hospital care and follow-up utilizing criteria, guidelines,
high risk screens and clinical judgment.
- Performs assessment of physiological, psychosocial and
functional status to facilitate early discharge planning in
collaboration with patient and/or family, physician and
interdisciplinary healthcare team.
- Facilitates and coordinates discharge planning interventions
along with quality of care while ensuring utilization of resources
is seamless along the continuum, based on the needs of the
individual patients and availability of local delivery
- All referrals, pre-certification, concurrent and retrospective
reviews will be performed, and the provider and member notified of
the results within the regulatory required timeframe.
- Collaborates with and provides direction to physicians, other
members of multi- disciplinary healthcare team, patient and/or
family in the development, implementation, and documentation of
appropriate, individualized care plans to ensure continuity quality
and appropriate resource utilization.
- Educates physicians, other members of healthcare team, and
patient and/or family regarding interpretation and application of
Medicare, Medicaid and Health plan benefits and coverage and its
interrelationships with efficient and appropriate resource
utilization and member out of pocket costs.
- Negotiates with non-contracted providers to minimize patient
out of pocket costs and maximize continuity of care. Point of
contact to ensure appropriate payment of claims to maximize members
benefit and available dollars.
- Investigates, prepares and refers cases not meeting established
criteria and/or requiring Medical Director (QRM) review per
established department guidelines.
- Inserts appropriate physician and/or coverage language and
issues letters of non - coverage to members not meeting established
medical necessity criteria and ensures patient and/or family
understand appeal rights and assist with alternative resources if
able and available.
- Establishes and maintains contact with patients and their
families as appropriate, including the provision of education when
- Collaborates with physicians and providers to ensure that
healthcare resources are provided at the appropriate level of care
and in the most appropriate setting based on established criteria
- Identify per program criteria and refer appropriate members to
case management, disease management, risk management and quality
- Coordinates transmission of clinical and benefit information to
patient, family, physician and/or provider remaining HIPPA
- Provide correspondence, written and verbal, in accordance to
policy and procedure for members with respect to status of
pre-certification and utilization review.
- Per established protocols or triggers, reports any incidence of
unusual occurrences to quality, risk and/or patient safety to the
- Remains knowledgeable of contract benefits and current,
relevant state and Federal regulations, criteria, documentation
requirements, Nurse Practice Act and laws that affect managed care
and case/utilization management.
- Builds effective working relationships with physicians and
providers and acts as liaison with other departments.
- Assists in the development, implementation and revision of
Utilization policies, procedures, guidelines, pathways and
- Investigates, identifies and reports problems and
inefficiencies in existing systems, and recommends changes when
appropriate to the Director, QRM.
- Monitors utilization trends in the market area, keeping
appropriate management informed and makes recommendations for
opportunities. Initiates recommendations to facilitate improvement
in quality of care and appropriate utilization and cost
- Works cross-functionally with other departments in striving to
meet organizational goals and objectives.
- Other duties as assigned.
- Minimum three (3) years Utilization Management experience, to
include discharge planning and quality improvement in a managed
- Minimum three (3)years of clinical nursing.
- Graduate of an accredited school of nursing.
License, Certification, Registration
- Driver's License (California)
- Registered Nurse License (California)
- Registered Nurse License (Virginia)
- Registered Nurse License (Maryland)
- Registered Nurse License (District of Columbia)
- Registered Nurse License (Hawaii)
- Registered Professional Nurse License (Georgia)
- Working knowledge of all local, state and federal and
- Excellent organizational, oral and written communication and
problem-solving and decision-making skills.
- Excellent analytical skills.
- Professional image and behavior.
- Ability to interpret financial data, calculate figures and
amounts such as discounts, interest, commissions, proportions, and
- Ability to solve practical problems and deal with a variety of
concrete variables in situations where only limited standardization
exists. Ability to interpret a variety of instructions furnished in
written, oral, diagram or schedule form. Ability to negotiate
- Ability to read and interpret documents such as contracts,
procedure manuals, operations and maintenance instructions. Ability
to compose reports and correspondence.
- Excellent windows-based navigation skills.
- Three (3) years Utilization Management experience in a
Preferred Provider Organization preferred.
- Bachelors degree in Nursing or Healthcare preferred.
- Certified in Utilization Management or Review (or within one
year of hire) preferred.
- Experience with URAC and NCQA accreditation process
PrimaryLocation : California,Oakland,1800 Harrison
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-PO-01-NUE-Non Union
Job Level : Individual Contributor
Job Category : QA, UR & Case Management
Department : Po/Ho Corp - National Case Installation - 0315
Travel : Yes, 10 % of the Time
Kaiser Permanente is an equal opportunity employer committed to a
diverse and inclusive workforce. Applicants will receive
consideration for employment without regard to race, color,
religion, sex (including pregnancy), age, sexual orientation,
national origin, marital status, parental status, ancestry,
disability, gender identity, veteran status, genetic information,
other distinguishing characteristics of diversity and inclusion, or
any other protected status.
Keywords: Kaiser Permanente, Oakland , Utilization Management Nurse, Executive , Oakland, California
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