UM Prior Authorization Review Nurse - RN Job at UCLA Health, Los Angeles, CA

VlJ5SlNNdE5oQXlwVmdQdUJUU1NYeGlRVXc9PQ==
  • UCLA Health
  • Los Angeles, CA

Job Description

Description At UCLA Health, the Utilization Management (UM) Review Nurse plays a vital role in ensuring the delivery of high-quality, evidence-based care. This position is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility. This role works collaboratively with medical directors, physicians, and interdisciplinary teams to support appropriate care coordination and efficient utilization of resources. Key Responsibilities: + Conducts clinical reviews of prior authorization requests to evaluate medical necessity and benefit coverage. + Applies UCLA Health protocols and national clinical guidelines (e.g., InterQual, Milliman) in review decisions. + Coordinates escalations to medical directors and ensures timely documentation of determinations. + Communicates with providers to obtain clarification and support the decision-making process. + Ensures compliance with CMS, state, federal, and UCLA Health standards. + Reviews and validates cases submitted by non-clinical staff. + Audits documentation to ensure compliance and accuracy. + Provides mentorship and feedback to coordinators to enhance workflow efficiency. + Collaborates with UCLA Health medical directors and interdisciplinary teams for case resolution. + Serves as a liaison between clinicians, internal departments, and members. + Documents all review findings and decisions in the case management system and supports reporting initiatives. + Educates providers and staff on UM policies, criteria, and review processes. + Identifies process improvement opportunities and contributes to performance improvement projects. + Remains current with clinical best practices and UM regulatory changes. Salary Range: $61.79 - $79.91 Hourly Qualifications + BSN and/or MSN required + Current California RN license required + Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills required + Proficient knowledge in evidence-based medical necessity criteria, health plan medical necessity criteria and CMS criteria required + A minimum of three years of experience in utilization management, preferred + Team leading or management experience, preferred + Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high-volume work environment + Strong critical thinking and the ability to apply knowledge + Ability to work effectively and collaboratively with interdisciplinary teams + Proficient computer skills including Internet search capabilities, Microsoft Word, Excel, and Managed Care software (i.e. EZ Cap, Diamond, IDX) required + Ability to effectively communicate to physician/staff the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. + Ability to effectively communicate to the payer the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. + Skill in setting priorities that accurately reflect the relative importance of job responsibilities. + Skill in abstracting and interpreting medical information from patient records. + Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS. + Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel. UCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person's unique achievements and experiences to further set us apart.

Job Tags

Hourly pay,

Similar Jobs

BruntWork

Remote Digital Accessibility Tester Job at BruntWork

 ...Mon-Fri 9am-6pm CST includes 1 hr unpaid break Role Overview: We are seeking a skilled and detail-oriented Digital Accessibility Tester to help ensure that our digital products and services are inclusive and accessible to users of all ages and abilities. In this... 

LV Collective

Video Production Summer 2025 Intern Job at LV Collective

 ...a someone who loves everything about the video making process and believes that video can...  ...is like working with an in-house video production team? Have you ever wondered what it takes...  ...are seeking a dependable, self-motivated intern with a strong interest in online video production... 

Lloyd Agencies

Remote - Client Success Manager Job at Lloyd Agencies

 ...completing their applications. Company Overview Lloyd Business Services is a trusted national provider of life and supplemental...  ...optional team calls for mentorship and updates What Youll Gain Remote work with control over your schedule Weekly commission pay... 

Boston Legacy FC

VP of Marketing Job at Boston Legacy FC

 ...on and off the pitch. We are passionate about advancing womens sports, investing in our local community, and redefining the future of...  ...Officer | Hybrid (3-4 days in office) The Role The VP of Marketing will be responsible for launching and leading all marketing efforts... 

Resurrection Ascension Catholic Academy

Physical Education Teacher Job at Resurrection Ascension Catholic Academy

We are seeking a physical education teacher to teach grades PK-8 two or four days a week. Applicant must be versed in age appropriate curriculum and activities for each age group.