Senior RN Case Manager: Utilization & Care Coordination

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

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