Utilization Review Representative

Children’s Hospital of Orange County; United States; On-site; USD 61,000 - 101,000; Full time

Job summary

CHOC, the Children’s Hospital of Orange County, is seeking a Utilization Review Representative in Orange, CA. You will perform utilization reviews for inpatients and outpatients and handle authorization requests with payors in collaboration with RN Care Managers.

The role requires nursing experience in acute or ambulatory settings, LVN licensure in CA, and relevant certifications. Strong communication and organizational skills are essential, with a focus on accuracy and patient advocacy.

Qualifications

• Licensed Vocational Nurse (CA) license required.
• Nursing experience in acute or ambulatory care preferred.
• Certifications in Utilization Review and/or Case Management; CPN preferred.

Responsibilities

• Perform utilization review for all inpatient and outpatient statuses.
• Process internal and external authorization requests with payors for treatments, services and supplies.
• Assist RN Care Manager with case load and data collection.
• Verify insurance and provide financial counseling and customer service.
• Ensure accuracy and completeness of work across responsibilities.

Skills

Communication

Conflict resolution

Problem solving

Negotiation

Time management

Multi-tasking

Independent judgment

Teamwork

Education

Licensed Vocational Nurse CA

BLS Certification

Tools

Microsoft Office

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 Rate of pay is determined by various factors, including but not limited to knowledge, skills, competencies, experience, education, as well as position requirements.

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.

Recognized year after year as national leader in employee engagement, and named one of the best children’s hospitals by U.S. News & World Report, this is an exciting time to be at CHOC. Our campus is constantly growing and offering new state-of-the art programs and services as we continue to meet the needs of more than 250,000 children annually, making the opportunities for career enrichment endless. We offer highly competitive salary levels and benefits, but the personal growth and fulfillment you’ll find at CHOC, coupled with an inspiring mission to nurture, advance, and protect the health and well being of children, are perhaps the most valuable payouts of all. We hope you will join our dedicated and talented team of associates committed to the highest standards of care and making a difference in the lives of children in Orange County – and beyond. 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. We're always in search for our next Defender of Childhood!