RN Utilization Review Specialist | Case Management

Torrance Memorial Medical Center; Torrance (CA); On-site; USD 77,000 - 120,000; Full time

Job summary

Torrance Memorial Medical Center is seeking a Utilization Review Case Manager to review patient charts and validate appropriate levels of care using InterQual/MCG criteria. The role secures payer authorizations through collaboration with payers and healthcare teams, ensuring CMS utilization review standards are met.

The UR CM engages with RN Case Managers, physicians, patients, and families to optimize discharge planning and documentation while maintaining regulatory compliance and quality

Qualifications

• RN license required.
• 1+ year of acute hospital case management experience.
• Experience with payer communications and authorizations.

Responsibilities

• Review patient charts to ensure appropriate level of care.
• Utilize InterQual/MCG criteria for reviews and authorizations.
• Collaborate with payers, RN Case Managers, and physicians.
• Document outcomes and maintain compliance with regulatory standards.
• Identify and communicate discharge planning needs and equipment requirements.
• Support staff orientation and competency assessments.

Skills

Discharge planning

Payer communication

Denial management

Interdisciplinary collaboration

Documentation

MCG criteria knowledge

Patient care documentation

Education

Bachelor's degree in Nursing

Tools

MCG criteria

Job description

Torrance Memorial Medical Center is seeking a Utilization Review Case Manager to review patient charts and validate appropriate levels of care using InterQual/MCG criteria. The role secures payer authorizations through collaboration with payers and healthcare teams, ensuring CMS utilization review standards are met.

The UR CM engages with RN Case Managers, physicians, patients, and families to optimize discharge planning and documentation while maintaining regulatory compliance and quality