Clinical Utilization Review Case Manager

Torrance-Memorial-Medical-Center; Torrance (CA); On-site; USD 78,000 - 120,000; Full time

Job summary

Torrance-Memorial-Medical-Center seeks an experienced Utilization Review Case Manager (RN) to review patient charts and validate appropriate levels of care using InterQual/MCG criteria. The UR CM secures payer authorization and communicates with payers throughout the stay, ensuring compliance with CMS and Joint Commission standards.

The role involves collaborating with RN Case managers, physicians, and external case managers, documenting thoroughly, and supporting denial prevention and discharge

Qualifications

• RN license required.
• Bachelor's degree in Nursing.
• 1–2 years acute hospital case management experience.

Responsibilities

• Review patient charts using MCG criteria for admission and continued stay.
• Obtain payer authorization for clinical services.
• Collaborate with RN Case Managers, physicians, and payers to mitigate denials.
• Document daily activities and ensure compliance with regulations.
• Coordinate transfer and discharge planning with care teams.

Skills

Interdisciplinary collaboration

Medical necessity review

Time management

Documentation

Education

Bachelor's degree in Nursing

Tools

MCG criteria

InterQual criteria

Job description

Torrance-Memorial-Medical-Center seeks an experienced Utilization Review Case Manager (RN) to review patient charts and validate appropriate levels of care using InterQual/MCG criteria. The UR CM secures payer authorization and communicates with payers throughout the stay, ensuring compliance with CMS and Joint Commission standards.

The role involves collaborating with RN Case managers, physicians, and external case managers, documenting thoroughly, and supporting denial prevention and discharge