Per Diem RN Case Manager - Utilization Management - Days - Remote

University of California, Irvine•Orange, CA

4d•Remote

About The Position

Incumbent is responsible for implementing the utilization management process for patients admitted to the hospital. Monitors and coordinates resource utilization throughout the health system and evaluates services provided. Performs inpatient admission and concurrent review functions utilizing medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria). Reviews clinical documentation, communicates with physician and other clinical staff to ensure documentation accurately reflects the patient’s severity of illness, and collaborates with health plans/ payors by providing clinical information as required. Analyzes and identifies utilization patterns and trends and participates in denial prevention and management, appeals, special studies, projects, audits, or routine utilization monitoring activities while ensuring compliance with applicable regulatory, payer and organizational requirements.

Requirements

Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties.
Must possess complete understanding of acuity levels for specific patient population.
Must demonstrate customer service skills appropriate to the job.
Minimum 5 years of clinical experience and 1 year of previous Case Management experience or a UCI employee who meets the clinical requirements and has a BSN.
Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail).
Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job.
Familiarity of Joint Commission, CMS, CDPH and CCS requirements.
Excellent written and verbal communication skills in English.
Current RN License.
Computer literacy and proficiency.
All external candidates must have a Bachelor of Science in Nursing.
Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload.
Ability to establish and maintain effective working relationships across the Health System.
Must be able to provide proof of work authorization.

Nice To Haves

Knowledge of University policies and procedures.
Knowledge of California Children's Services benefits authorization process (CCS).
CCM, ACM.
Bilingual skills.

Responsibilities

Implementing the utilization management process for patients admitted to the hospital.
Monitoring and coordinating resource utilization throughout the health system and evaluating services provided.
Performing inpatient admission and concurrent review functions utilizing medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria).
Reviewing clinical documentation.
Communicating with physician and other clinical staff to ensure documentation accurately reflects the patient’s severity of illness.
Collaborating with health plans/ payors by providing clinical information as required.
Analyzing and identifying utilization patterns and trends.
Participating in denial prevention and management, appeals, special studies, projects, audits, or routine utilization monitoring activities while ensuring compliance with applicable regulatory, payer and organizational requirements.