Pediatric Utilization Review Nurse, South San Francisco, CA
PEDIATRIC UTILIZATION REVIEW NURSE
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Pediatric Utilization Review Nurse to perform utilization reviews ensuring that HPSM’s pediatric members receive necessary medical care in a timely and cost-effective manner. This position will include the following essential duties & responsibilities:
- Conducts concurrent reviews of inpatient care, and reviews authorization requests for inpatient care.
- Provides care coordination for members who are transitioning from one level of care to another.
- Processes authorization requests for various services, including but not limited to: outpatient, rehabilitation and/or home health services.
- Conducts in-person patient assessments and/or home visits to ascertain patient’s level of need (as needed).
- Maintains collaborative and cooperative relationships with other HPSM departments and partners.
- Maintains and enhances relationships between HPSM and the provider community.
- Provides back-up for other UR 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 the pediatric population. 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