Registered Nurse - Utilization Manager

Decypher; Patterson (CA); On-site; USD 51,052 - 72,711; Full time

Benefits offered by this job

Health & Wellness Incentive

Job summary

A healthcare services provider seeks a Registered Nurse - Utilization Manager in California to assist with inpatient discharge planning and develop a comprehensive Utilization Management program. Candidates must have an ADN or BSN, relevant nursing experience, and a Registered Nurse License. This role includes monitoring specialty care referrals and conducting medical necessity reviews. The position offers full-time hours, Monday to Friday, with compensation of $44.92 per hour plus potential health incentives.

Qualifications

• Valid, active, unrestricted Registered Nurse License.
• Basic Life Support (BLS) certification required.
• 4 years of experience if ADN holder; 2 years if BSN holder.

Responsibilities

• Assist with inpatient discharge planning and coordinate transfers.
• Develop and implement a Utilization Management program.
• Monitor specialty care referrals for appropriateness and authorization.

Skills

Clinical documentation analysis

Communication skills

Data collection and analysis

Discharge planning

Understanding of healthcare resources

Education

Associate degree in Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Electronic health records

Clinical decision tools

Job description

Job Summary

The Registered Nurse - Utilization Manager must have the ability to sit or stand for extended periods while reviewing medical records and working on a computer, with frequent use of standard office equipment and clear verbal and written communication. Must have sufficient visual acuity and attention to detail to analyze complex clinical documentation, with occasional ability to move about the workplace and lift up to 10–15 pounds.

Required Qualifications

• Education:
  • Associate degree (ADN) or
  • Bachelor of Science in Nursing (BSN) from a program accredited by a national nursing accrediting agency recognized by the U.S. Department of Education.
• Certifications:
  • Basic Life Support (BLS)
• License: Valid, Active, Unrestricted Registered Nurse License
• Experience:
  • 4 years of experience if ADN holder; 2 years of experience if BSN holder - in discharge planning or case management.
  • Full‑time employment in a nursing field within the last 36 months is required.
• U.S. Citizenship is required

Key Responsibilities

• Assist with inpatient discharge planning as needed, including home safety patient/family
• interviews, attending morning planning meetings, and coordinating transfers, home durable medical equipment, home care services, inpatient rehabilitation, and skilled care.
• Develop and implement a comprehensive Utilization Management (UM) program aligned with Military Treatment Facility (MTF), Air Force (AF), and Defense Health Agency (DHA) goals and objectives.
• Collect, analyze, and trend data/metrics on program areas to identify over‑ and underutilization of healthcare resources, inefficiencies, and areas for cost containment. Provide reports, feedback, and recommendations in a timely manner.
• Monitor specialty care referrals, ensuring appropriateness, covered benefits, and authorization for medical procedures, laboratory, radiology, and pharmacy services.
• Evaluate clinical practice patterns and trends, providing feedback to the Chief of Hospital Services (SGH) and clinical teams.
• Identify and refer potential cases to Disease Management, Case Management, Discharge Planning, and the Deployment Availability Working Group.
• Participate in Medical Management, Population Health Working Group, and care coordination meetings as assigned.
• Conduct nursing peer reviews as assigned.
• Educate Patient‑Centered Medical Home (PCMH) staff on the role of Utilization Management.
• Assist the PCMH team in notifying patients admitted to civilian hospitals or civilian emergency departments.
• Perform medical necessity reviews, including concurrent reviews for length of stay (LOS) using approved clinical decision tools. Assess medical necessity of services and communicate negative trends to the Chief of the Medical Staff.
• Navigate electronic health records and TRICARE managed care contractor sites.
• Act as referral approval authority for designated referrals based on MTF/AF/DHA national guidance and standards, including processing and validating durable medical equipment referrals for PRIME beneficiaries and authorizing Supplemental Health Care Program (SHCP) funds for active‑duty beneficiaries.
• Refer all first‑level review failures to SGH or designated points of contact for further review and disposition.
• Verify beneficiary eligibility using the Defense Eligibility Enrollment Reporting System (DEERS). Obtain pertinent patient information and update electronic medical records, local referral databases, and other office automation systems as needed.
• Perform other duties as assigned.

Work Environment & Schedule

Monday - Friday; 8 hour shifts 7:00am - 16:30 with a 30‑minute uncompensated lunch.

Compensation & Benefits

$44.92 per hour + $4.93 Health & Wellness Incentive (IF APPLICABLE)

Decypher is an equal opportunity and affirmative action employer committed to a diverse and inclusive workforce (M/F/D/V)