RN Case Manager EX - Utilization Management - Days - Remote - Irvine

UCI Health; Irvine (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

UCI Health in Irvine, CA, seeks an experienced Utilization Management nurse to implement the utilization management process for patients admitted to the hospital. You will monitor resource use across the health system, perform inpatient admission and concurrent reviews using decision-support criteria, and ensure documentation reflects severity of illness.

The role requires RN license, BSN, 5+ years clinical experience in acute care, and knowledge of payer authorization, denial prevention, and

Qualifications

• Minimum 5 years of recent clinical experience (within last 10 years) in an acute care adult setting and 1 year of Case Management/ Utilization Management.
• Knowledge of payer authorization and concurrent review processes, including continued-stay reviews and communication with health plans.
• Knowledge of denial prevention, denial management, retrospective review, appeals, and/or peer-to-peer processes preferred.
• Familiarity with Joint Commission, CMS, CDPH, CCS, Medicare, Medi-Cal and commercial health plan requirements applicable to utilization management and hospital services.
• Excellent written and verbal communication skills in English.

Responsibilities

• Implement the utilization management process for patients admitted to the hospital.
• Monitor and coordinate resource utilization throughout the health system and perform inpatient admission and concurrent reviews using decision-support criteria (InterQual/MCG).
• Review clinical documentation to ensure accuracy of severity of illness and communicate with physicians and staff.
• Collaborate with health plans/payors by providing clinical information as required and participate in denial prevention/management and audits.

Skills

Customer service skills

Excellent communication skills

Ability to manage multiple projects

Ability to collaborate across Health S

Verbal communication in English

Education

Bachelor of Science in Nursing

RN License

BLS Certification

Tools

InterQual

MCG

Microsoft Excel

Microsoft Word

PowerPoint

Access

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.

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.

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.

Required Qualifications

What It Takes to be Successful

• Working knowledge of acute-care utilization management criteria and decision-support tools, including InterQual and/or MCG
• Proficient in Microsoft Office suite (Excel, Word, PowerPoint, Access)
• Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties.
• Must possess complete understanding of acuity levels for the adult patient population
• Must demonstrate customer service skills appropriate to the job
• Minimum 5 years of recent clinical experience (within the last 10 years) in an acute care adult setting and 1 year of previous Case Management, Utilization Management, or a related acute care coordination experience for the adult population.
• Knowledge of payer authorization and concurrent review processes, including submission of clinical information, continued-stay reviews, and communication with health plans and medical groups.
• Knowledge of denial prevention, denial management, retrospective review, appeals, and/or peer-to-peer processes preferred.
• Familiarity of Joint Commission, CMS, CDPH and CCS, Medicare, Medi Cal and commercial health plan requirements applicable to utilization management and hospital services
• Excellent written and verbal communication skills in English
• Demonstrated knowledge of utilization management principles, medical necessity, level-of-care determination, concurrent review, InterQual or other recognized clinical decision-support criteria, payer requirements, and denial prevention/management.
• Current RN License
• Computer literacy and proficiency
• Bachelor of Science Nursing Degree
• 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
• CCM, ACM

Licenses And Certifications

• RN
• BLS

Education

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.

• 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