Overview: The Senior Utilization/Case Management Nurse is responsible for facilitating care coordination and care transition with the goal to promote optimum health outcomes throughout the care continuum for MediCal, Medicare, and commercial populations. Primary responsibilities include advanced 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 considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of departmental procedures and clinical guidelines. The Sr. UM/CM Nurse will assess the member/patient and develop a care plan in collaboration with the member/patient, caregiver/family, the multidisciplinary care team, and the member/patient’s Health Plan (as necessary). The Sr. UM/CM Nurse will continue to monitor progression of the care plan and intervene, in collaboration with the multidisciplinary care team, to ensure the member/patient’s goals are met and inpatient readmissions and emergency room visits are prevented. The position requires telephonic, web based, and onsite clinical reviews; therefore, the employee will need to use their private auto for travel to our various health centers, contracted hospitals, or other locations for offsite meetings. Essential Duties and Responsibilities: Sr. UM/CM Nurse’s responsibilities include, but are not limited to: • Assessment, planning, intervention, monitoring and evaluation of assigned patients/members and development of care plans with input from the member/patient, caregiver/family, multidisciplinary care team and Health Plan, as necessary. • Conduct advanced 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, assess member medical and psychosocial needs. • Acquire appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy for care coordination and care plan monitoring/update. Accurately applies coding guidelines. • Identify appropriate health care resources based on member's medical needs, including but not limited to working with the Contracts team to facilitate contracts or letters of agreement with facilities/vendors. • Using professional judgment, independent analysis and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc. to care plan development and case review. • UM/CM case review summarization including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans. • Makes approval determinations, as needed, 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. • Present care plans to Medical Director for review and input for cases with significant barriers to care, complex medical needs, or any other issues affecting progression of care plan goals. • Interact with the providers or patients/members as appropriate to communicate referral determinations outcomes in compliance with state, federal and accreditation requirements. • Develop and/or review appropriate documentation and correspondence reflecting referral determinations. Ensures documentation is accurate, complete and conforms to established regulatory standards. • Document all care plan and case review 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 Tri-Counties Regional Center (TCRC). • Identify and refer members who may benefit from disease management, health education, social services, or behavioral health 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. • Coordinate UM/CM review and care plan 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.