The Sr. UM/CM Nurse performs advanced and complicated case review and first level determination approvals from inpatient, outpatient, and ancillary services requests, exclusive to State Health Plans population (e.g. Medi-Cal). 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 acts as liaison between the member/patient, the primary care provider, specialist(s), ancillary provider, and the designated Health Plan (e.g. Gold Coast Health Plan, Inc.) to promote appropriate and cost effective use of medical resources. Essential duties and responsibilities include, but are not limited to: • Conducting UM/CM case summarization including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans. • Making first level approval determinations when requests meet appropriateness, medical necessity and benefit criteria. • Interacting with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements. • Documenting all activities as per unit practice, including entry into automated systems. Recognizing potential quality care concerns and referring as appropriate. • Conducting rate negotiations, when necessary as per policy, with non-network providers, utilizing appropriate reimbursement methodologies.