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Job Field: Office Jobs
Location: Central Valley, CA
Salary: $Not stated

JOB SUMMARY:

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<tr><td valign="top" width="450"><b>Title: Utilization Management Nurse Reviewer*Location: California-Central Valley-CeresOther Locations:Responsibilities include but are not limited to the prospective, concurrent and retrospective review of service utilization and quality care for the SGMF&#39;s HMO contracted members. To identify health care delivery inefficiencies and using a case management approach, assist in the appropriate resolution to these problems.Sutter Gould Medical Foundation (SGMF)is a non-profit, multi-specialty health care organization affiliated with Sutter Health. Based in Modesto, SGMF provides quality medical care, health education and research activities in a five-county area. SGMF&#39;s medical staff includes family practitioners, internists and pediatricians, as well as a range of specialist physicians. Services include imaging, nuclear medicine, a health library, health education programs, occupational medicine, diabetes education, nutrition counseling, infertility counseling, and weight management. Current RN license with a minimum of one (1) years recent managed care experience or LVN license with a minimum of three(3) to four(4) years recent managed care experience or a Bachelor''s degree in nursing with a minimum of one(1) year of Utilization management experience. Prior experience with Utilization Management in an acute or physician setting. Acute care nursing experience. Knowledge of capitated health plan benefit structures, financial matrices, utilization management processes and philosophy. Demonstrated excellent communications skills, as well as demonstrated ability dealing with medical professionals. Possess well-developed writing, problem identification, analytical and problem resolution skills. Ability to establish priorities, set goals and coordinate multiple activities to meet deadlines. Knowledge of computer systems and applications.

KEY REQUIREMENTS:

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Not stated