Registered Nurse - Utilization Management - 8 Hour Per Deim

Cedars-Sinai; Los Angeles (CA); On-site; USD 95,000 - 125,000; Full time

Job summary

Cedars-Sinai is seeking an Utilization Review Case Manager to assess medical necessity and optimize patient care. You will collaborate with physicians, care teams, and payers to secure timely authorizations and coordinate discharge planning in a fast-paced hospital setting.

Ideal candidates bring 3+ years of acute nursing and 2+ years in case management, with strong clinical judgment and communication skills. Licensure as an RN is required, CPT coding experience preferred.

Qualifications

• Graduate of an accredited nursing program (ASN/AD) as minimum.
• Bachelor's degree in nursing preferred.
• Active RN license required.
• 3 years in acute nursing
• 2 years Case Management preferred
• 1 year CPT coding preferred.

Responsibilities

• Assess medical necessity, appropriateness, and efficiency of patient care services.
• Coordinate with physicians, care team, and payers to secure timely authorizations.
• Monitor length of stay and discharge planning to optimize resources.
• Identify barriers to discharge and help reduce denials through documentation.
• Ensure regulatory compliance and accurate reimbursement through documentation.

Skills

Clinical judgment

Critical thinking

Communication

Collaboration

Education

ASN/AD Nursing

BSN preferred

Tools

InterQual criteria

MCG criteria

CMS Two‑Midnight Rule

Job description

Job Description

The Utilization Review Case Manager is responsible for assessing the medical necessity, appropriateness, and efficiency of patient care services. Utilizing evidence-based clinical criteria such as InterQual, MCG, and the CMS Two-Midnight Rule. The UR Case Manager performs initial, concurrent, and retrospective reviews to ensure accurate patient status, appropriate level of care, and optimal length of stay. In this role, the UR Case Manager collaborates closely with physicians, care coordinators, payers, and the interdisciplinary care team to secure timely authorizations, optimize utilization of hospital resources, and support high-quality, patient-centered outcomes. The UR Case Manager proactively identifies barriers to discharge, monitors patient progression, and helps reduce denials through precise documentation and effective communication. The incumbent requires strong clinical judgment, critical thinking, and communication skills, along with the ability to work both independently and collaboratively in a fast-paced, multidisciplinary environment. Serving as a key liaison between the clinical team and payers, the UR Case Manager plays a vital role in ensuring regulatory compliance, appropriate reimbursement, and safe, efficient, patient-centered care.

Qualifications

Education

• Assoc. Degree/College Diploma Graduate of an accredited nursing program - minimum
• Bachelor's Degree Nursing - preferred

Experience

• 3 years In acute nursing - minimum
• 2 years Case Management - preferred
• 1 year CPT coding - preferred

Licenses and Certifications

• RN State License - minimum
• Basic Life Support (BLS) - minimum