UM Outpatient Licensed Clinician

Summary Reporting to the Outpatient Lead Clinician, the UM Outpatient Licensed Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and ensure high-quality medical outcomes.

Duties and Responsibilities:

Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to: Promote improved quality of care and/or life Prevent hospitalization when possible and appropriate Provide for continuity of care Ensure appropriate levels of care are received by members Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers Identify complex authorization requests and appropriately refer to Case Management personnel Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests Work effectively with all other sub team members within Outpatient UM Maintain prompt and open communication with Denial team to meet tight turnaround time (usually with 24hours of initial request) Communicate with Health Plan Liaisons if a precertification request requires health plan review, ensuring review is completed in compliance with timeliness standards Outreach to Provider Network Operations team to address provider related referral insufficiencies Identify appropriate alternative and non-traditional resources and creatively manage each case to fully utilize all available resources Comply with accuracy and timeliness standards in accordance with CMS, DHCS, & Health Plan regulations. Maintain knowledge of UM policy and procedures Establish effective rapport during phone calls with other employees, professional support service staff, customers, clients, members, families, and physicians Attend all mandatory onsite and virtual meetings to ensure alignment with team goals, project updates, and organizational communication.

Minimum Job Requirements:

Current California RN or LVN license 2+ years of experience in utilization management preferred Proficiency with Microsoft Office Programs; primarily Word and Excel EZ-CAP® knowledge a plus

Skills and Abilities:

Excellent relationship management skills with the ability to communicate effectively with all stakeholders Strong organizational, task prioritization, and delegation skills Ability to collaborate successfully with all levels of the organization

Salary Range:

LVN $36-$39/hr; RN $42-$48/hr