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UM Nurse ID-11066

April 11, 2025

General Summary: UM Nurse focuses on the Gonzaba Medical Group UM Review Process.

Supervisory Responsibilities: This position has no supervisory responsibilities.

General Requirements: All duties performed will be done accurately and in a timely manner.

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Carries out GMG UM Program activities and UM Operations.
Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
Participates in educational programs as needed.
Maintains strict confidentiality practicing HIPAA rules and regulations.
Other duties as assigned.
Bilingual English/ Spanish fluency preferred.
Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.

Essential Job Responsibilities

Provides clinical perspective/input to Review team, UM team and Referral Specialists.
Summarizes medical records documentation for physician medical necessity review.
Composes Denial letters according to CMS defined standards and according to UM delegation rules.
Applies evidenced-based criteria to medical necessity reviews and documents appropriately in review summary.
Performs daily authorization oversight to insure proper completion of referral documentation in EZ Cap and EMR, timeliness of determinations and compliance with UM Delegation requirements in daily operations.
Pulls, validates, and submits ODAG reports, Part C reports and other UM reports to health plans upon request, meeting submission deadlines.
Successfully performs live ODAG reviews with health plan auditors; successfully responds to “desk review” requests, by submitting screenshots and documents within defined timeline.
Contributes to delegation audits and fulfilling certain requirements for UM delegation related to making UM criteria available to requesting providers upon request, non-contracted providers are consistently identified appropriate State, OIG, MCR opt out screenings are carried out prior to approving the referral service. Ensure use of Board-Certified Specialists in making referral decisions. Other UM requirements for training, monitoring performance measures, etc.
Ensures GMG UM team responds timely to inquiry from claims vendor where an authorization has NOT been obtained previously.
Identifies opportunities for operational improvement, and works collaboratively with UM team, Provider PODS, and other GMG departments.
Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers.
Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed.
Promotes the Contracted Network Providers to GMG patients and staff.

Work Environment: Office environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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DISCLAIMER

UM Nurse ID-11066

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?