Per Diem RN Case Manager - Utilization Management - Days - Remote

University-of-California,-Irvin; Orange (CA); Remote; USD 110,000 - 140,000; Full time

Job summary

UCI Health seeks an experienced nurse to implement utilization management for hospitalized patients. You will monitor resource use, review documentation and coordinate with physicians to reflect illness severity, while working with health plans to provide necessary clinical information.

Requirements include a BSN and an active RN license, plus 5 years of clinical experience and familiarity with regulatory standards.

Qualifications

• Minimum 5 years of clinical experience and 1 year of Case Management experience or a UCI employee who meets the clinical requirements and has a BSN.
• Knowledge of Joint Commission, CMS, CDPH and CCS requirements.
• Excellent written and verbal communication skills in English.
• Current RN License.
• All external candidates must have a Bachelor of Science in Nursing.
• Computer literacy with MS Windows, Excel, Access, Word, PowerPoint and internet/email.
• Ability to manage multiple concurrent projects and maintain a suitable workload.
• Ability to establish and maintain effective working relationships across the Health System.

Responsibilities

• Implement utilization management process for hospitalized patients.
• Monitor and coordinate resource utilization across the health system.
• Review clinical documentation and communicate with physicians to ensure accurate reflection of severity of illness.
• Collaborate with health plans/payors by providing clinical information as required.
• Analyze utilization patterns and participate in denial prevention, appeals, and routine monitoring.

Skills

Customer service

Verbal communication

Written communication

Regulatory knowledge

Computer literacy

Multitasking

Education

Bachelor of Science in Nursing (BSN)

Tools

MS Windows

Excel

Access

Word

PowerPoint

Email

Job description

Who We Are

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health - Orange, UCI Health - Irvine, four Community Network hospitals and a growing network of ambulatory care centers across Orange and Los Angeles counties. As Orange County’s only academic health system, UCI Health is home to the only National Cancer Institute-designated comprehensive cancer center based in the county, the region’s only American College of Surgeons-verified Level I adult and Level II pediatric trauma center, American College of Emergency Physicians Gold Level 1 Geriatric Emergency Department and a nationally recognized regional burn center verified by the American Burn Association. Powered by UC Irvine, UCI Health serves 5.6 million people across Orange County, western Riverside County and southeast Los Angeles County through excellence in patient care, research and medical education.

Your Role on the Team

Position Summary

Incumbent is responsible for implementing the utilization management process for patients admitted to the hospital. Monitors and coordinates resource utilization throughout the health system and evaluates services provided. Performs inpatient admission and concurrent review functions utilizing medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria). Reviews clinical documentation, communicates with physician and other clinical staff to ensure documentation accurately reflects the patient’s severity of illness, and collaborates with health plans/ payors by providing clinical information as required. Analyzes and identifies utilization patterns and trends and participates in denial prevention and management, appeals, special studies, projects, audits, or routine utilization monitoring activities while ensuring compliance with applicable regulatory, payer and organizational requirements.

What It Takes to be Successful

Required Qualifications

• Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties
• Must possess complete understanding of acuity levels for specific patient population
• Must demonstrate customer service skills appropriate to the job
• Minimum 5 years of clinical experience and 1 year of previous Case Management experience or a UCI employee who meets the clinical requirements and has a BSN.
• Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job
• Familiarity of Joint Commission, CMS, CDPH and CCS requirements
• Excellent written and verbal communication skills in English
• Current RN License
• Computer literacy and proficiency
• All external candidates must have a Bachelor of Science in Nursing
• Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload
• Ability to establish and maintain effective working relationships across the Health System

Preferred Qualifications

• Knowledge of University policies and procedures
• Knowledge of California Children's Services benefits authorization process (CCS)
• CCM, ACM
• Bilingual skills

Total Rewards

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

Conditions of Employment

The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:

• Background Check and Live Scan
• Employment Misconduct
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

• California Child Abuse and Neglect Reporting Act
• E-Verify
• Pre-Placement Health Evaluation

Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php

Closing Statement

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy.

We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.

UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at [e-mail] or at [phone], Monday - Friday from 8:30 a.m. - 5:00 p.m.

Consideration for Work Authorization Sponsorship

Must be able to provide proof of work authorization