Utilization Review Case Manager: Acute Care & Appeals
Palomar Health
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Job summary
Palomar Health is seeking a Clinical Resource Management RN to drive utilization management for acute care patients. You will conduct daily concurrent reviews, support discharge planning, and communicate with health plans and case managers to ensure appropriate care and timely authorization.
In this role you will collaborate with the care team during Interdisciplinary Rounds, participate in denial reviews and appeals, and analyze utilization patterns.
Qualifications
- Minimum Education: As required by certification and/or licensure.
- Preferred Education: Bachelor's Degree and/or National Certification in Utilization Review or Case Management.
- Minimum Experience: 1-3 years of directly related RN experience.
- Preferred Experience: 3-5 years acute care nursing experience.
- Required Certification: Not Applicable
- Required License: Current CA RN License
Responsibilities
- Implement utilization management for patients admitted to acute care.
- Conduct daily concurrent reviews for utilization/quality management.
- Provide telephonic or fax reviews to health plans/medical groups.
- Collaborate with Case Managers and care team during Interdisciplinary Rounds.
- Participate in retro reviews and appeals for denied services.
- Analyze utilization patterns and support data collection for studies.
Skills
Education
Tools
Job description
Palomar Health is seeking a Clinical Resource Management RN to drive utilization management for acute care patients. You will conduct daily concurrent reviews, support discharge planning, and communicate with health plans and case managers to ensure appropriate care and timely authorization.
In this role you will collaborate with the care team during Interdisciplinary Rounds, participate in denial reviews and appeals, and analyze utilization patterns.
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