Job Description

Utilization Management RN - PT/Days

SUMMARY: The Utilization Management Nurse supports the case management department by by providing a variety of utilization management functions including but not limited to daily screening of patient admission relative to specified criteria, active involvement in denial management, acting as a resource to staff regarding clinical criteria, communication with payors to address concerns and other duties as assigned. The Utilization Management Nurse will work collaboratively with the Utilization Nurse Program Coordinator to ensure compliance with regulatory, organizational and department requirements. The Utilization Review Nurse will receive direction from the Utilization Review Program Coordinator for daily and long term tasks and projects.

Denial Management Experience is highly desirable. Oversee the appeal process for denials to ensure timely and effective appeals. Writes appeal letters which include clear documentation of information, including clinical evidence, to support the appeal. Monitors denial volumes and appeal outcomes. Reports to UM Subcommittee on the appeal outcomes, as requested. Reviews denials for trends from payers and reports trends to UM Management.

POSITION REQUIREMENTS: A) a graduate from an accredited nursing program. BSN or 4 year-degree in related field strongly preferred; B) an active California Registered Nurse licensure (RN); C) Minimum 3 years full time RN experience in an acute care hospital setting, pediatric experience and experience in case management and/or utilization Review strongly preferred.

Additional required skills: A) Knowledge of Utilization Management and private and public payer reimbursement practices and procedures; B) Excellent organizational and communication skills with ability to work with a variety of health care professionals; C) ability to work independently; D) Proficient in work processing, spreadsheets and database software.

POSITION DETAILS: Part Time, 40 hours per pay period, must be available for shifts every other weekend.


Application Instructions

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