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

      Level 1 - LVN:

• Conduct clinical review for service requests for medical appropriateness and medical necessity using clinical judgment, independent analysis, and 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.
• Research member issues and assess member needs related to authorization requests.
• Acquire appropriate clinical records, clinical guidelines, policies, EOC and benefit policy. Accurately applies coding guidelines.
• 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 to member and providers reflecting determination. Ensure documentation is accurate, complete and conforms to established regulatory standards.
• Document all activities as per department practice including entry into automated systems. Recognizes potential quality of care concerns and refers as appropriate.
• Make appropriate referrals to California Children’s Services (CCS) and Tri-Counties Regional Center (TCRC).
• Identify and refer members who may benefit from care coordination programs, such as disease management or case management, and make appropriate referrals.                                             
• Attend meetings or meet with staff within the organization as assigned.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.

LEVEL 2 - RN: (in addition to above)

• Conduct clinical review for service 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.
• Utilizes strong critical thinking skills for complex clinical reviews and care coordination.
• Ensures that assigned health plans are meeting or exceeding Medicare/Medicaid/Commercial  performance benchmarks per health plan contracts.
• Builds and maintains relationships with internal and external clinical teams to help resolve barriers to referrals and care.
• Acts as a clinical resource to LVN staff. 
• Begins to influence department's strategy and provide constructive feedback to Medical Management leadership.
• Makes decisions on moderately complex to complex issues regarding technical approach for project components, such as Medical Management system enhancements, and work is performed with minimal direction.