8337 Management jobs in Yorba Linda
Customer Service Helpdesk - Customer Success Manager
Posted 13 days ago
Job Viewed
Job Description
We are looking for a proactive and relationship-driven Customer Success Manager (CSM) to join our growing team. As a CSM, you will serve as the primary point of contact for a portfolio of clients, ensuring they receive exceptional support, value from our products/services, and a seamless experience throughout their journey.
Your mission is to drive customer satisfaction, retention, and growth by building trusted relationships, solving problems, and identifying opportunities for expansion.
Key Responsibilities:- Own and manage relationships with a portfolio of customers, serving as their strategic advisor
- Onboard new clients, ensuring smooth product adoption and implementation
- Drive customer engagement and product usage through training, support, and communication
- Monitor account health and proactively address issues before they escalate
- Collaborate with Sales, Product, and Support teams to deliver an exceptional customer experience
- Identify upsell, cross-sell, and renewal opportunities in collaboration with the Sales team
- Analyze customer data and feedback to recommend improvements to product and service delivery
- Conduct regular check-ins (QBRs, calls, reports) to review progress, ROI, and goals
- Maintain up-to-date records in CRM systems (e.g., Salesforce, HubSpot)
- 2+ years of experience in Customer Success, Account Management, or a related client-facing role
- Strong interpersonal and communication skills (written & verbal)
- Highly organized with a proven ability to manage multiple accounts and priorities
- Comfortable with CRM and CS platforms (e.g., Salesforce, Gainsight, Zendesk, Intercom)
- Problem-solving mindset with a passion for helping others succeed
- Ability to work independently and cross-functionally in a fast-paced environment
Company Details
Office Manager
Posted 13 days ago
Job Viewed
Job Description
We are seeking a highly organized and proactive Remote Office Manager to oversee administrative operations, coordinate virtual workflows, and support team productivity across departments. The ideal candidate will be self-motivated, tech-savvy, and experienced in managing business functions in a fully remote environment.
Key Responsibilities:- Manage and optimize daily remote office operations, tools, and workflows
- Oversee calendar scheduling, virtual meeting logistics, and team-wide communications
- Serve as the main point of contact for internal staff regarding office-related queries
- Assist with onboarding/offboarding processes and maintaining digital employee records
- Coordinate with IT, HR, and Finance departments to support organizational needs
- Track inventory of software licenses, equipment, and office budgets
- Organize virtual events, team-building activities, and internal communications
- Ensure compliance with remote work policies, procedures, and data security standards
- Monitor general email inboxes and route inquiries appropriately
- Assist executive leadership with administrative tasks and special projects
- Proven experience as an Office Manager, Administrative Manager, or similar role
- Excellent written and verbal communication skills
- Strong organizational, time management, and problem-solving abilities
- Proficient in tools like Google Workspace, Slack, Zoom, Asana, Notion, and Microsoft 365
- Ability to work independently and support a distributed team across time zones
- Familiarity with HR, IT, or basic accounting processes is a plus
- High level of discretion and professionalism
Company Details
Client Services Associate
Posted 24 days ago
Job Viewed
Job Description
Job Summary: We are seeking a dedicated Client Services Associate to support our financial consultants in providing excellent customer service to our clients. You will work closely with our staff, preparing documents before client meetings, organizing sales and presentation materials, compiling meeting notes, and setting up client access for new accounts. On a daily basis, you will also handle other administrative tasks, such as answering phone calls emails, sending deadline reminders to consultants, and updating our client database.
Duties and Responsibilities
- Compile and update necessary documents and contracts
- Prepare presentation materials
- Gather meeting notes and input them to client files
- Obtain and process all client information and transactions
- Create new accounts and maintain client portfolios
- Perform administrative and clerical duties as necessary
Requirements and Qualifications
- High school diploma or equivalent; associate or bachelor's degree in business, finance, or related field preferred
- Experience as a Client Services Associate or other administrative role in the financial industry a plus
- Proficient in Microsoft Office
- Strong communication and organizational skills
- Detail-oriented
- Comfortable working independently
- Exceptional customer service skills
Company Details
RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient popubilation served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Lead, mentor, and support utilization management staff including nurses and coordinators.
- Serve as a resource and subject matter expert on utilization management processes, policies, and regulations.
- Assist with onboarding, and training, of team members.
- Manage staffing assignments and workloads to meet service-level goals and compliance metrics.
- Monitor daily workflow for timely completion of authorization reviews (pre-certification, concurrent, post-service).
- Ensure appropriate application of clinical guidelines (e.g., InterQual, MCG) and regulatory standards (e.g., CMS, NCQA, URAC).
- Collaborate with medical directors for escalations or complex case reviews.
- Identify trends, delays, or denials and propose improvements.
- Monitor adherence to UM policies, procedures, and applicable federal/state laws.
- Participate in audits, accreditation surveys, and quality improvement initiatives.
- Develop and implement strategies to enhance utilization management effectiveness and member outcomes.
- Ensure accurate documentation and data integrity in UM systems.
- Serve as a liaison between utilization management, care coordination, provider relations, and payers
- Facilitate regular team meetings and cross-functional updates.
- Respond to escalations from providers, members, and internal stakeholders. Other duties as assignedsuch as denials management and appeals in lieu of other UM duties.
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
#LI-MM1
MLKCH Video
RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient popubilation served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Lead, mentor, and support utilization management staff including nurses and coordinators.
- Serve as a resource and subject matter expert on utilization management processes, policies, and regulations.
- Assist with onboarding, and training, of team members.
- Manage staffing assignments and workloads to meet service-level goals and compliance metrics.
- Monitor daily workflow for timely completion of authorization reviews (pre-certification, concurrent, post-service).
- Ensure appropriate application of clinical guidelines (e.g., InterQual, MCG) and regulatory standards (e.g., CMS, NCQA, URAC).
- Collaborate with medical directors for escalations or complex case reviews.
- Identify trends, delays, or denials and propose improvements.
- Monitor adherence to UM policies, procedures, and applicable federal/state laws.
- Participate in audits, accreditation surveys, and quality improvement initiatives.
- Develop and implement strategies to enhance utilization management effectiveness and member outcomes.
- Ensure accurate documentation and data integrity in UM systems.
- Serve as a liaison between utilization management, care coordination, provider relations, and payers
- Facilitate regular team meetings and cross-functional updates.
- Respond to escalations from providers, members, and internal stakeholders. Other duties as assignedsuch as denials management and appeals in lieu of other UM duties.
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
#LI-MM1
MLKCH Video
RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient popubilation served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Lead, mentor, and support utilization management staff including nurses and coordinators.
- Serve as a resource and subject matter expert on utilization management processes, policies, and regulations.
- Assist with onboarding, and training, of team members.
- Manage staffing assignments and workloads to meet service-level goals and compliance metrics.
- Monitor daily workflow for timely completion of authorization reviews (pre-certification, concurrent, post-service).
- Ensure appropriate application of clinical guidelines (e.g., InterQual, MCG) and regulatory standards (e.g., CMS, NCQA, URAC).
- Collaborate with medical directors for escalations or complex case reviews.
- Identify trends, delays, or denials and propose improvements.
- Monitor adherence to UM policies, procedures, and applicable federal/state laws.
- Participate in audits, accreditation surveys, and quality improvement initiatives.
- Develop and implement strategies to enhance utilization management effectiveness and member outcomes.
- Ensure accurate documentation and data integrity in UM systems.
- Serve as a liaison between utilization management, care coordination, provider relations, and payers
- Facilitate regular team meetings and cross-functional updates.
- Respond to escalations from providers, members, and internal stakeholders. Other duties as assignedsuch as denials management and appeals in lieu of other UM duties.
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
#LI-MM1
MLKCH Video
RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient popubilation served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Lead, mentor, and support utilization management staff including nurses and coordinators.
- Serve as a resource and subject matter expert on utilization management processes, policies, and regulations.
- Assist with onboarding, and training, of team members.
- Manage staffing assignments and workloads to meet service-level goals and compliance metrics.
- Monitor daily workflow for timely completion of authorization reviews (pre-certification, concurrent, post-service).
- Ensure appropriate application of clinical guidelines (e.g., InterQual, MCG) and regulatory standards (e.g., CMS, NCQA, URAC).
- Collaborate with medical directors for escalations or complex case reviews.
- Identify trends, delays, or denials and propose improvements.
- Monitor adherence to UM policies, procedures, and applicable federal/state laws.
- Participate in audits, accreditation surveys, and quality improvement initiatives.
- Develop and implement strategies to enhance utilization management effectiveness and member outcomes.
- Ensure accurate documentation and data integrity in UM systems.
- Serve as a liaison between utilization management, care coordination, provider relations, and payers
- Facilitate regular team meetings and cross-functional updates.
- Respond to escalations from providers, members, and internal stakeholders. Other duties as assignedsuch as denials management and appeals in lieu of other UM duties.
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
#LI-MM1
MLKCH Video
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RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient popubilation served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Lead, mentor, and support utilization management staff including nurses and coordinators.
- Serve as a resource and subject matter expert on utilization management processes, policies, and regulations.
- Assist with onboarding, and training, of team members.
- Manage staffing assignments and workloads to meet service-level goals and compliance metrics.
- Monitor daily workflow for timely completion of authorization reviews (pre-certification, concurrent, post-service).
- Ensure appropriate application of clinical guidelines (e.g., InterQual, MCG) and regulatory standards (e.g., CMS, NCQA, URAC).
- Collaborate with medical directors for escalations or complex case reviews.
- Identify trends, delays, or denials and propose improvements.
- Monitor adherence to UM policies, procedures, and applicable federal/state laws.
- Participate in audits, accreditation surveys, and quality improvement initiatives.
- Develop and implement strategies to enhance utilization management effectiveness and member outcomes.
- Ensure accurate documentation and data integrity in UM systems.
- Serve as a liaison between utilization management, care coordination, provider relations, and payers
- Facilitate regular team meetings and cross-functional updates.
- Respond to escalations from providers, members, and internal stakeholders. Other duties as assignedsuch as denials management and appeals in lieu of other UM duties.
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
#LI-MM1
MLKCH Video
RN Utilization Management Lead
Posted today
Job Viewed
Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
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RN Utilization Management Lead
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Job Description
POSITION SUMMARY
The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements.
The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
POSITION REQUIREMENTS
A. Education
- Associates Degree in Nursing or equivalent required. BSN preferred.
B. Qualifications/Experience
- Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
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