Due to growth in membership over the past year (60,000 new members) and large influx of claim reviews/appeals, we are in need of additional nurses to support the mandated turnaround timeframes of the Utilization Management unit. The Utilization Management nurse uses a multi-disciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care and/or service requests focusing on selected complex medical and psychosocial needs of CCHP members and their families. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors to perform first level review. To pre-certify elective services, procedures and test utilizing established Care Coordination policies and protocols, CCHP benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.

If this action is not approved and without additional staff, Contra Costa Health Plan's Utilization Management unit will not be able to meet the mandated requirements of the Plan.

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