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Job Information Job #2326: Healthcare in Whittier, California

Job #2326: Healthcare

Job Code:#2326

Title:Utilization Management RN

Job Type:Contract

Job Location:Whittier CA

Job Description:


Global Service Resources, Inc., a leading Healthcare staffing company has an opening for RN Case Manager UM at our local government client location.


  • UM Nurse Reviewer needed not really a case management position.

  • Need someone with exp in UM review.

  • IPA UM.I need a nurse who worked in an IPA or Health Plan that worked in the UM department reviewing requests for services.

  • The UM review nurse will need to know how to refer to CMS, Noridian, Health Plan web sites for clinical criteria and MCG.

  • outpatient prior auth exp

  • could be there till June 2018 and could be travel to perm

  • 0830-1700, M-F

  • business casual dress

  • Safeguards and preserves the confidentiality of patient’s protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies.

  • Ensures a safe patient environment and adherence to safety practices per policy.

  • With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care.

  • Receives reviews, verifies and processes requests for referrals, diagnostic testing, inpatient admissions, outpatient procedures/testing, emergency room notification, home health care services, and durable medical equipment and supplies via telephone or fax.

  • Completes all documentation accurately and appropriately for data entry in the utilization management system at the time of the telephone call of fax to include any authorization updates.

  • Reviews all requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.

  • Screens requests for the Medical Director review, assuring the gathering of pertinent medical information prior to submission to the Medical Director and follows up per standard time frame to the requester with the decision by the Medical Director and documents this follow-up in the utilization management system.

  • Meets identified productivity and quality of work standards on an ongoing basis.

  • Demonstrates support of the plan’s need to be cost effective in terms of resources, material, and time.

  • Familiar with the functions of other departments of the Plan and maintains a positive working relationship.

  • Takes the initiative to develop, establish, and follow a sensible work priority system to help deal with day-to-day activities as well as heavy workload.

  • Maintains confidentiality of the member’s medical information.

  • Refers cases of possible over/under utilization to the Medical Director for reporting to the Utilization Committee.

  • Assist PA Manager in identifying areas of staff training needed, and in maintaining current date resources.

  • Screen and process referrals in a timely accurate basis utilizing established guidelines from Regulators, health plan and MCG.

  • Responsible to adhere to ICE Turn-Around-Times (TAT) per line-of-business.

  • Responsible to act as department resource for telephone inquiries regarding referrals issued (e.g., referral status, procedures on how to request authorization, etc.); research problems pertaining to referrals with primary care practitioners, specialists, patients and health plans.

  • Coordinate referrals for transplant and transplant related services with the Complex Case Management (CCM) Nurse

  • Ensure referrals are made to appropriate vendors according to financial responsibility

  • Responsible to provide appropriate language for denial letters and denial reasons to meet Health Plan and regulatory requirements

  • Attend quarterly Utilization Management Committee (UMC) meetings, to present cases , if applicable

  • Perform other duties as assigned


  • the UM nurse specialist provides organizational support in the Utilization Mgmt Dept. efficiently processes Pre-Service Authoritzation requests. works with UM Coordinators.

  • needs to have : 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.

  • education/experience/training required : formal training will be indicated by a high school diploma or equivalent, current license as a RN or LVN in the state of CA, min of 2 yrs exp in a health plan or managed care IPA or Medical Group in UM.


At Global Service Resources Healthcare, we concentrate on building careers and we offer attractive compensation packages.

  • Medical Insurance

  • Vision Insurance

  • Prescription Drug Card Coverage

  • Paid Private Housing or Housing Stipend

  • Paid Travel Allowance

  • Mileage Reimbursement

  • 401(K) savings plan with employer match (soon to come)

  • Hours Bonus

  • Referral Bonus Program

  • Free Direct Deposit

  • Paid Professional Liability insurance

  • Paid training

  • Continuing Education assistance

*Benefits available according to company policy.

References will be requested if called for an interview.

Since the job needs to be filled immediately please email your resume as soon as possible.

We will contact you on receipt!

Thank you,

Global Service Resources, Inc.

Jessica Gonzalez HernandezRecruiter, Global Service Resources

Main (818)244-4484 Ext.9202 (tel:Main (818)244-4484 Ext.9202) | Direct: (818) 252-9202 (tel:Direct: (818) 252-9202) | On-Call 818-640-5033 | Fax: (818) 306-6174 (tel:On-Call 818-640-5033 | Fax: (818) 306-6174) | |