Utilization Review Representative

CHOC; Town of Florida (NY); On-site; USD 40,000 - 68,000; Full time

Job summary

CHOC in Orange, California seeks an experienced Utilization Review Representative to assess inpatient and outpatient statuses and manage authorization requests with payors. You will collaborate with RN Care Managers and support data collection, insurance verification, and financial counseling, ensuring accuracy and quality of service.

The role requires LVN licensure in California, BLS and preferred case-management credentials, with a focus on pediatric care and patient advocacy.

Qualifications

• Graduate of an accredited Licensed Vocational Nursing program.
• Preferred: Graduation with a Bachelor’s Degree in nursing from an accredited University.
• Certification in Utilization Review and/or Case Management; CPN.

Responsibilities

• Responsible for utilization review of inpatient and outpatient statuses.
• Process daily authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers Inpatient and Outpatient.
• Assist in the completion of the RN Care Manager’s case load, promoting data collection, insurance verification, financial counseling and customer service.
• Ensure work processed is accurate and complete in all areas of responsibilities.

Skills

Communication

Conflict resolution

Insurance verification

Customer service

Data gathering

Healthcare knowledge

Education

Licensed Vocational Nurse – CA

BLS Certification

Bachelor’s degree in Nursing

Job description

Work Location

Orange, California

Work Shift

Day – 08hrs (United States of America)

Why CHOC?

At CHOC, we strive to be the leading destination of children’s health by providing exceptional and innovative care. We are responsible for the overall health of our community’s pediatric population in our hospitals, clinics, and practices. And because of our breadth of care, your career at CHOC can be as diverse and fulfilling as you determine. CHOC’s compensation structure, benefits offerings, and career development programs are geared to helping you achieve your professional and personal goals.

Environmental Sustainability Statement

Driven by the connection between children’s health and a healthy environment, we commit to creating a healthcare model that incorporates environmental sustainability aligned with our mission to protect children’s health and patient safety.

Job Summary

The Utilization Review Representative is responsible for utilization review of all inpatient and outpatient statuses. This individual is also responsible for the daily processing of internal and external authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers Inpatient and Outpatient. Will assist in the completion of the RN Care Manager’s case load as assigned, promoting a positive approach to all activities related to data collection, insurance verification, financial counseling and customer service. This role ensures that the work processed is accurate and complete in all areas of responsibilities.

Pay Range

Minimum $29.48 Midpoint $39.04 Maximum $48.61

Experience

• Required: 2 years of acute care or ambulatory care experience.
• Preferred: Over one (1) year of nursing experience in an acute care or ambulatory setting. One (1) + years of pediatric nursing experience and prior experience as Utilization Review nurse.

Education

• Required: Graduate of an accredited Licensed Vocational Nursing program.
• Preferred: Graduation with a Bachelors Degree in nursing from an accredited University.

Training

• Required: None required.
• Preferred: Certification in Utilization Review and/or Case Management; CPN.

Specialized Skills

• Required: Ability to work effectively under pressure due to changing priorities, interruptions, high/low census, payor demands and discharge planning demands. Excellent interpersonal communication, including conflict resolution, problem solving and negotiation skills. Clinical knowledge of multiple age groups, medical illness, and treatment plans according to disease process, diagnosis, and anticipated LOS. Strong organizational and time management skills, as evidenced by capacity to multi-task and prioritize. Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients, and their families. Demonstrates the knowledge and skills necessary to communicate with third party payers to obtain authorization for the appropriate treatment setting for patients requiring medical, psych, and chemical dependency treatment. Must be proficient in required competencies upon completion of orientation and maintain annual departmental competency requirements. Ability to work collaboratively regardless of social, economic and cultural backgrounds. Computer knowledge to include skills in using Microsoft Office (Excel, Word, Power Point, Access).
• Preferred: Knowledge of CCS/Medi-Cal regulations and requirements; Knowledge of third party payor requirements in order to optimize reimbursement; Ability to apply severity of illness/ intensity of service pediatric criteria to information extracted from clinical documentation; Demonstrate knowledge of third party payor methods; bilingual.

Licensure

• Required: Licensed Vocational Nurse – CA (LVN), Basic Life Support (BLS).
• Preferred: Ped Emerg Assess Recog & Stabil (PEARS); Comprehensive Crisis Management (CCM); Certified Pediatric Nurse (CPN).

Work Environments – Functional Demand:

Light - Moderate energy level Lift and carry 25-35 lbs. Push/pull 50-100 lbs. (ie. empty bed, stretcher).

Physical Activity Requirements:

Bending, Carry Objects, Climbing, Keyboard use/repetitive motion, Pinching/fine motor activities, Push/Pull, Reaching forward, Reaching overhead, Sitting, Squat/kneel/crawl (Squad & Knee), Standing, Talk or hear, Taste or smell, Twisting, Walking, Wrist position deviation

Physical Activity Lifting

Lifting (Floor to waist level) - Occasional 0-35%, Lifting (Waist level and above) - Occasional 0-35%

Sensory Requirements:

Color Discrimination, Depth Perception, Far Vision, Hearing, Near Vision

Environment Requirements:

Airborn Communicable Disease, Bloodborne Pathogens, Chemical, Dust Particular Matter, Extreme Noise Levels, Extreme Temperatures, Radiation, Uneven Surfaces or Elevations

Non-Discrimination Statement:

CHOC does not discriminate on the basis of age, race, color, religion, national origin, ancestry, marital status, genetic information, disability, sex, gender (including pregnancy, breastfeeding, childbirth, lactation or related medical conditions), gender identity or expression, medical condition, sexual orientation, veteran status, military or uniformed service member status, or other protected characteristics in accordance with state and federal laws. CHOC will consider for employment qualified applicants with criminal histories, in accordance with the Fair Chance Initiative for Hiring.

We encourage individuals from all backgrounds to apply for positions at CHOC, even if your experience doesn’t align perfectly with the listed qualifications for a particular role, as your unique experience may be a great addition to our culture for another one of our opportunities.

If you desire support or accommodations throughout the Talent Acquisition process, please inform your Talent Acquisition Partner.