Under the general supervision of the Quality and Utilization Management Director, the Utilization Management Nurse performs case review and first level determination approvals for inpatient, outpatient, and ancillary services requests.  Reviews include benefit determination, medical appropriateness, and medical necessity determination requiring clinical judgment, critical-thinking skills, and detailed knowledge of departmental procedures and clinical guidelines.   ESSENTIAL FUNCTIONS AND RESPONSIBILITIES   The UM Nurse’s responsibilities include, but are not limited to:   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. 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. 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 reflecting determination. Ensure 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 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 disease management or case management and make appropriate referrals. Manages out of area cases/requests based on current policy and refers them to the primary insurer as appropriate.   Attend meetings or meet with staff at various health centers as assigned. Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.