Essential Duties and Responsibilities

CM Nurse’s responsibilities include, but are not limited to:

• Conduct clinical review for inpatient, out-patient and ancillary services requests

for medical appropriateness and medical necessity using considerable clinical

judgment, independent analysis, critical-thinking skills and detailed knowledge of

medical policies, clinical guidelines and benefit plans.

• Review, triage, and prioritize authorization requests to meet required turn-around times.
• Expedite access to appropriate care for members with urgent or immediate

needs using the expedited review process.

• Perform research and analyze complex issues, assesses member needs.
• Acquire appropriate clinical records, clinical guidelines, policies, EOC and Benefit

Policy. Accurately applies coding guidelines.

• Identify appropriate health care resources based on member's medical needs,

including but not limited to evaluating contracts and negotiating with

facilities/vendors.

• Using professional judgment, independent analysis and critical-thinking skills,

applies clinical guidelines, policies, benefit plans, etc. to case review.

• UM/CM case summarization including analysis of medical records and

appropriate application of all applicable policies, guidelines and benefit plans.

• Makes first level approval determinations when request meets appropriateness,

medical necessity and benefit criteria.

• Develop determination recommendations and present cases to Medical Director

(or designee) for potential denial determinations or when Medical Director input is

needed.

• Interact with the providers or members as appropriate to communicate

determination outcomes in compliance with state, federal and accreditation

requirements.

• Develop and/or review appropriate documentation and correspondence reflecting

determination. Ensures documentation is accurate, complete and conforms to

established regulatory standards.

• Document all activities as per unit practice including entry into automated

systems. Recognizes potential quality care concerns and refers as appropriate.

• Make appropriate referrals to California Children’s Services (CCS) and TriCounties

Regional Center (TCRC).

• Identify and refer members who may benefit from disease management or case

management and make appropriate referrals.

• Identifies potential TPL/COB cases, investigates TPL/COB issues, and notifies

the appropriate internal departments.

• Manages out of area cases/requests based on current policy and refers them to

the primary insurer as appropriate.

• Conducts rate negotiation, when necessary and as per policy, with non-network

providers, utilizing appropriate reimbursement methodologies.

• Documents rate negotiation accurately for proper claims adjudication.
• Coordinate UM/CM review activities with contracted and/or delegated entities, as

needed.

• Attend meetings as assigned.
• Meet with staff at various health centers as assigned.
• Perform additional duties as assigned.