RN Utilization Manager: Optimize Care & Resources

Adventist Health; Roseville (CA); On-site; USD 81,000 - 112,000; Full time

Job summary

Adventist Health in Roseville, CA seeks an RN with utilization review experience to assess the necessity and appropriateness of treatments and to optimize resource use. You will coordinate with care teams, insurers, and patients to ensure efficient, high-quality care while maintaining financial stewardship.

Required RN licensure with at least five years acute hospital experience and two years in utilization review using Optum/Inter Qual within the last year.

Qualifications

• Associate's Degree in nursing or equivalent combination of education/related experience: Required
• Bachelor's Degree in Nursing (BSN): Preferred
• Five years' acute hospital experience required with preferred experience in critical care areas: Required
• Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required

Responsibilities

• Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay.
• Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals.
• Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals.
• Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate.
• Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process.

Skills

RN licensure

Utilization review

Education

Associate's Degree in nursing

BSN preferred

Tools

Optum/Inter Qual

Job description

Adventist Health in Roseville, CA seeks an RN with utilization review experience to assess the necessity and appropriateness of treatments and to optimize resource use. You will coordinate with care teams, insurers, and patients to ensure efficient, high-quality care while maintaining financial stewardship.

Required RN licensure with at least five years acute hospital experience and two years in utilization review using Optum/Inter Qual within the last year.