Utilization Management Nurse, Senior

Your Role

The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their families. The FEP Utilization Management Nurse will report to the FEP Utilization and Medical Review Manager. In this role you will be part of a dynamic team responsible for prior authorization and concurrent review medical reviews. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit. Ultimately, contributing to decreasing the cost of healthcare.   

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work 

In this role, you will:

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP 
• Conducts clinical review of prior authorization requests for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Ensure discharge(DC) planning at levels of care appropriate for the members needs and 
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
• Actively participates in staff meetings and huddles 
• Provides input into desk level procedures

Your Knowledge and Experience  

• Requires a bachelor's degree or equivalent experience
• Bachelor's of Science in Nursing or advanced degree preferred
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• Previous experience in utilization management preferred
• Strong computer skills related to Windows-based programs and applications
• Varied acute care clinical background 
• Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision