Intake Nurse - Utilization Management

About the role

Under the direction of the Director of Utilization Management, UM Clinical Manager and the UM Outpatient Clinical Supervisor, the RN Clinical Intake Coordinator is responsible for supporting the clinical Utilization Management activities for members. Conducts medical necessity review of referral requests including but not limited to requests for DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. Utilizes Milliman Care Guidelines and Medi-cal criteria to facilitate decision making. Refers cases to the Medical Director when clinical information provided in the referral request does not support medical necessity. Functions as a key resource to the Non-Clinical Intake Coordinators for questions or clarifications on criteria, interpretation of benefits, or whenever they need additional clinical expertise and/or guidance.

 Essential Duties and Responsibilities

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