Job Description

Job Description

Job Description

Utilization Review Nurse Manager openings in the Sacramento, CA 95833 area with a major health insurance / managed care company! Starting ASAP!! Apply now with Jake Z. at A-Line!

Position Purpose:

• Queue Management
• Will need to help improve turnaround times, ensure cases are being met, performing quality reviews (looking at nurses’ documentation and process to ensure that they are being done and being done well)
• Some process improvement required (working w/managers on non-clinical side to develop improvements & how things flow back and forth between the team)
• Participate in Meetings w/vendors and be able to report out on meetings

Pay: $45 - $52

Hours: Monday-Friday 8am-5pm; Weekend coverage as needed when staff work intermit/all remotely

Required Education & Experience:

• RN's Only, with at least 3 years of Management experience (Something within management of nurses-workers comp is OK)
• Working knowledge and understanding of basic utilization management and quality improvement concepts.
• Managed care experience including Prior authorization experience, Care/Case management, and Queue management experience
• Supervisor experience preferred, but open to candidates with strong clinical background and is progressing (i.e. Leads)

Job Responsibilities:

• Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
• Promote compliance with federal and state regulations and contractual agreements.
• Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
• Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
• Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
• Facilitate ongoing communication between utilization management staff and contracted providers.
• Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
• This manager will be overseeing the Appeals and grievances (provider and member) team, total 15-20 staff. There is one supervisor and one lead in the team. The supervisor has 15-20 nurses that report to her.

Why Apply:

• Full benefits available after 90 days: Medical, Dental, Vision, Life, Short-term Disability
• 401k after 1 year of employment: With employer match and profit sharing
• GREAT Hours! Monday through Friday, 40 hours per week
• Competitive Pay Rate

Keywords: Utilization Review, Utilization Management, Registered Nurse, MCO, RN, Nurse, Managed Care, Nurse Manager, URAC, CCM, Case Manager, Case Management, CMS, Medicare, Medicaid, Worker’s Comp, Grievance, Denials, Determination Review, Nurse Supervisor, RN Supervisor, Utilization Review Manager, UM, UR, Utilization Management RN, Utilization Management Nurse, Medical Claims, Appeals, Mail Order Medications, Insurance Verification, Pharmacy, Prior Authorization, Patient Counselor, Healthcare, Inbound Calls, Outbound Calls.

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