The Utilization/Case Management Nurse performs case review and first level determination approvals for inpatient, outpatient, and ancillary services requests, exclusive to a State Health Plans population (e.g. Medi-Cal). 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. The UM/CM Nurse acts as liaison between the member/patient, the primary care provider, specialist(s), ancillary provider, and the designated Health Plan to promote appropriate and cost effective use of medical resources. The position may require telephonic, web based, and/or onsite clinical reviews; therefore, the UM/CM Nurse will need to use their private auto for travel to our various health centers, contracted hospitals, and/or other locations for offsite meetings. Essential Duties and Responsibilities The UM/CM Nurse-s responsibilities include, but are not limited to: -Conduct clinical review for inpatient, outpatient, 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. -Research member issues and assess 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. -Use professional judgment and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc. to the member-s 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. 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. -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. Assists with transferring cases to in-area/in-network facility and provider as appropriate. -Conducts rate negotiation, when necessary and as per policy, with non-network providers, utilizing appropriate reimbursement methodologies. -Documents non-contracted rate negotiation accurately for proper claims adjudication. Rate negotiation must be approved by the Medical Director. -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.