Job description

The Health Plan of San Mateo (HPSM), a county organized health system founded in 1987, manages over 165,000 members’ health care, including all of our community’s Medi-Cal eligible residents is seeking a temporary Utilization Review Nurse to perform utilization reviews ensuring that HPSM’s members receive necessary medical care in a timely and cost-effective manner.

Position overview

· Review authorization requests/claims documentation within specified timeframes

· Review authorization requests for out-of-network inpatient facilities

· Clinically validate the medical appropriateness and coding accuracy of services rendered

· Utilize appropriate resources to guide review decisions and document decisions clearly and concisely

· Refer members to care coordination and case management as the need is identified during the review process

· Monitor, track, and report on all work conducted

Key skills

· Clear, concise, and professional written and verbal communication skills

Requirements

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

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

License and Certification:

· A valid California license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN)

Knowledge of:

· Computer applications, including proficiency in Microsoft Office Suite

· San Mateo County provider community and community resources

· Medicare and Medi-Cal coverage requirements and regulatory guidelines

Ability to:

· Work cooperatively with others, as part of a team and support team decisions

· Adapt to changes in requirements/priorities for daily and specialized tasks

· 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 form one level of care to another

· Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public

· Communicate effectively verbally and in writing

Salary and benefits

The starting salary range depends on the candidate’s work experience.

Temporary employees receive 24 hours of paid sick time per year.

Health Plan of San Mateo (HPSM) is a local County-funded nonprofit manages the health care for over 165,000 low-income people San Mateo County, including all its Medi-Cal eligible residents. HPSM is proud to be an Equal Opportunity Employer and an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.

Job Type: Contract

Pay: $37.00 - $54.00 per hour

Schedule:

• 8 hour shift

Experience:

• Utilization review: 1 year (Preferred)

License/Certification:

• RN (Preferred)

Work Location: Remote

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