Our mission is to make healthcare right. Together. We are a value-driven healthcare company committed to providing personalized care to aging and underserved populations. We do this by aligning stakeholders across the healthcare ecosystem. Together, we can improve consumer experience, optimize clinical outcomes, and reduce total cost of care.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.

SCOPE OF ROLE

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum.

ROLE RESPONSIBILITIES

Capacity to perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Capacity to review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines
Capacity to collaborate with the Medical Director to ensure the integrity of adverse
determination notices based on the quality standards for adverse determinations
Capacity to ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable.
Capacity to meet or exceed productivity targets set forth
Capacity to serve as a resource to non-clinical team members when applicable
Adheres to the Policies and Procedures set forth by the Quality Management Committee.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

Associate’s degree in Nursing, preferred
Minimum 2 years of experience in medical management clinical functions.
Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

Active and unrestricted license as a Licensed Vocational Nurse (LVN) in the state of CA is required
Certification Managed Care Nursing (CMCN) preferred

WORK ENVIRONMENT

The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
Some travel may be required.

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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