RN Utilization Management: Drive Efficient Patient Care

VetJobs; Los Angeles (CA); On-site; USD 93,000 - 103,000; Full time

Job summary

VetJobs is seeking a Utilization Review Case Manager in Los Angeles, CA to assess medical necessity and care levels using InterQual, MCG, and CMS Two‑Midnight Rule. You will collaborate with physicians, care coordinators, and payers to secure timely authorizations and optimize hospital resources.

The ideal candidate has an RN license, 3 years of acute nursing, and 2 years in case management; BLS and CPT coding experience are preferred. Salary range is $67.50–$75.00 per hour.

Qualifications

• RN license (state) required.
• BLS certification required.
• Minimum 3 years in acute nursing.
• 2 years case management preferred.
• 1 year CPT coding preferred.

Responsibilities

• Assess and determine appropriate care level using InterQual, MCG, and CMS Two‑Midnight Rule guidelines.
• Conduct initial and concurrent reviews for inpatient, observation, and outpatient services.
• Collaborate with physicians, care coordinators, and payers to support care progression and transitions.
• Verify orders with Medicare/Medicaid and other payers; clarify orders as needed.
• Advocate for payer resources for uninsured/underinsured patients.
• Communicate with third‑party payers providing timely clinical information.
• Track payer authorizations for dates of service; prevent coverage lapses.
• Overturn concurrent denials; assist with appeals processes.
• Monitor length of stay and progression; ensure efficient resource use.
• Identify and document barriers to discharge; escalate as needed.
• Maintain confidentiality and timely documentation.

Skills

InterQual

MCG guidelines

Two‑Midnight Rule

Clinical judgment

Communication skills

Teamwork

Education

Assoc. Degree in Nursing

Bachelor's in Nursing

Tools

CPT coding

Job description

VetJobs is seeking a Utilization Review Case Manager in Los Angeles, CA to assess medical necessity and care levels using InterQual, MCG, and CMS Two‑Midnight Rule. You will collaborate with physicians, care coordinators, and payers to secure timely authorizations and optimize hospital resources.

The ideal candidate has an RN license, 3 years of acute nursing, and 2 years in case management; BLS and CPT coding experience are preferred. Salary range is $67.50–$75.00 per hour.