Pre-employment modules may be required for this role. Please upload any certifications or health documents you have to your profile to expedite your on-boarding process.

Additional Details:

Required Skills/Experience:

• At least 1 year of experience must be on a medical/surgical ward or unit.
• Two years of experience as a Case Manager in a clinic or physician’s office performing utilization review or discharge planning may be considered as an alternative.
• California experience required.
• Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement.
• Must have utilization review and InterQual Guidelines experience.

Required Credentials: Highest level of education as stated on the resume.

Unit Details:

• Utilization review and discharge planning role.
• Reviews inpatient admission medical records for required documentation; obtains records required by payor agencies and initiates physician advisories for unwarranted admissions.
• Conducts ongoing reviews and discusses care changes with attending physicians and others.
• Formulates and documents discharge plans.
• Coordinates with multiple hospital services, the admitting office, clinic areas, correctional facilities, and other health care providers to support appropriate admissions, specialized testing, elective procedures, durable medical goods, and other services.
• Reviews and approves surgery schedules to ensure elective procedures are authorized.
• Answers provider questions regarding reimbursement, prior authorization, and documentation requirements; teaches providers payor source documentation requirements to maximize reimbursement to the hospital.
• May assist in training Utilization Review Nurse I staff.

Shift & Scheduling:

• Monday-Friday schedule with rotating weekend coverage.