UTILIZATION REVIEW NURSE
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Utilization Review Nurse to perform utilization reviews to ensure that HPSM members receive necessary medical care in a timely and cost-effective manner. This position will include the following essential duties and responsibilities:
- Conduct utilization reviews of inpatient facilities, including acute care, and/or process authorization requests for various services including but not limited to: outpatient, rehabilitation and/or home health services.
- Review authorization requests for out-of-network inpatient facilities.
- Provide care coordination of members who are transitioning from one level of care to another.
- Maintain collaborative and cooperative relationships with other HPSM departments.
- Maintain and enhance relationships between HPSM and the provider community.
- Provide back-up for other Utilization Review Nurses as needed.
License and Certification: A valid California license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN).
Education and Experience: Five (5) years clinical nursing experience. Experience with utilization management, disease management, and coordination of care within a managed care environment is preferred. A Bachelor’s degree in nursing or a related health services field is a plus.
Knowledge of: San Mateo County provider community and community resources. Medicare and Medi-Cal coverage requirements and regulatory guidelines. Utilize Access, Microsoft Office programs; perform internet research. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
Ability to: Ensure medical appropriateness and effective utilization of health care resources. Maintain timely compliance with all UM regulatory mandates. Ensure provider conformance to HPSM UM guidelines. Coordinate health services for members transitioning from one level of care to another. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies and the general public. Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds.
Starting Compensation Range: Between $40.86/hour-$48.07/hour - depending on experience.
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: firstname.lastname@example.org or via fax: (650) 616-8039. File by: Continuous until filled. EOE