Utilization Management Nurse Specialist (LVN), Full-Time/Remote

LOCAL CANDIDATES ONLY

The UM Nurse Specialist at PIH Health plays a vital role in the Utilization Management Department, ensuring the efficient processing of Pre-Service Authorization Requests and collaborating closely with UM Coordinators. As a key member of the team, the UM Nurse Specialist will be responsible for evaluating patient care needs, authorizing necessary services, and ensuring compliance with healthcare regulations and organizational policies. The ideal candidate will be a dynamic and compassionate professional with a strong understanding of managed care principles and the ability to apply appropriate UM criteria. They will possess excellent communication skills and the capacity to manage complex cases with a high level of organization. PIH Health values teamwork, innovation, and a dedication to the well-being of the communities it serves. For more information about PIH Health, please visit PIHHealth.org or follow us on social media platforms such as Facebook, Twitter, and Instagram.

Required Skills

• Current knowledge of Managed Care and Health Plan Division of Financial Responsibilities (DOFR)
• Ability to apply appropriate UM criteria
• Excellent communication skills
• Strong organizational capabilities
• Proficiency in electronic health record systems
• Understanding of medical terminology and coding
• Ability to work collaboratively with healthcare providers and administrative staff
• Knowledge of state and federal regulations pertaining to utilization management
• Critical thinking and problem-solving skills
• Attention to detail and accuracy in documentation
• Ability to prioritize tasks and manage time effectively
• Commitment to maintaining patient confidentiality and adhering to HIPAA guidelines

Required Experience

• High school diploma or GED
• Active California LVN License
• Minimum two years’ experience in a health plan or managed care IPA or Medical Group in UM
• Experience with pre-service authorization processes and criteria
• Familiarity with healthcare quality improvement processes
• Experience in patient advocacy and care coordination
• Understanding of healthcare reimbursement models and cost-containment strategies
• Experience working in a multidisciplinary team environment
• Preferred: Passed the Bilingual Fluency Assessment for Clinicians (BFAC Certified) by Language Line Solutions