RN Utilization Review

CommonSpirit Health Philanthropy; Long Beach (CA); In loco; USD 110.000 - 140.000; Tempo pieno

Descrizione del lavoro

CommonSpirit Health's St. Mary Medical Center in Long Beach, CA, seeks a Utilization Review Nurse to safeguard clinical decision-making, regulatory compliance, and efficient resource use.

You will review medical records, authorize services, and prepare cases for physician review in partnership with UM teams, ensuring care aligns with established criteria. The role requires CA RN licensure, AHA BLS, and strong UM/regulatory knowledge, with sharp analytical and organizational skills to support

Competenze

• Must have minimum two years of acute hospital clinical experience (or a Masters in Case Management or Nursing in lieu of 1 year).
• California RN license required (must live in California).
• AHA BLS certification.
• Ability to pass annual inter-rater reliability tests for Utilization Review products.
• Familiarity with managed care and payer environments beneficial.

Mansioni

• Review admission and continuation of stay decisions per Care Coordination Utilization Review guidelines.
• Ensure compliance with utilization review principles and regulatory criteria.
• Verify accuracy of patient status orders and address deficiencies with providers.
• Communicate review outcomes with physicians, payers, care coordinators and stakeholders.
• Collaborate with RN Care Coordinators to ensure progression of care; involve physician reviewers as needed.

Conoscenze

Acute hospital nursing

Critical thinking

Communication skills

Team collaboration

Time management

Formazione

CA RN license

Master's in Case Management or Nursing

Strumenti

MCG/InterQual guidelines

Descrizione del lavoro

Job Summary and Responsibilities

As our Utilization Review Nurse at the Utilization Management Hub, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization.

Every day you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria.

To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow.

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Job Requirements

• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• California RN license. Must Live in California.
• AHA BLS
• Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.
• Proficient in application of clinical guidelines (MCG/InterQual) preferred
• Knowledge of managed care and payer environment preferred.
• Must have critical thinking and problem-solving skills.
• Collaborate effectively with multiple stakeholders
• Professional communication skills.
• Understand how utilization management and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced, self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Preferred

• Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
• At least five (5) years of nursing experience.
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification

Where You'll Work

Founded in 1923, Dignity Health - St. Mary Medical Center is a 389-bed, acute care, nonprofit hospital located in Long Beach, California. Serving over 80,000 patients annually, the hospital offers a full complement of services including a Level II Trauma Center, Level III NICU, heart care, and orthopedics. Additionally, St. Mary Medical Center has been recognized as an LGBTQ+ Healthcare Equality High Performer by the Human Rights Campaign Foundation. It is a Joint Commission-certified Thrombectomy-Capable Stroke Center and received a Healthgrades 5-Star Award for Heart Failure in 2026.

One Community. One Mission. One California