Utilization Care Manager - St. Anne's Hospital

Brown Medicine•Los Angeles, CA

14d•$80,330 - $160,618•Hybrid

About The Position

The Utilization Care Manager reports to the Director of Care Management or designee and monitors medical necessity in patient care records. In collaboration with the physician of record and the Utilization Review Committee physician, the manager ensures patients receive the appropriate level of care and that admission and concurrent authorizations are obtained from third-party payers. The role supports high-quality, safe, and fiscally responsible care through timely use of resources and services. The position reviews admissions and ongoing care, coordinates with physicians and payers, supports patient appeals, and provides guidance to patients and healthcare staff on care options and regulatory requirements. It also works with Care Coordination to identify discharge readiness, improve patient flow, and address service delays. The work is performed in a general hospital environment, primarily on site, with duties across patient care areas.

Requirements

Current Registered Nurse license in Rhode Island, or RN licensure under the Nurse Licensure Compact agreement.
Bachelor’s degree in Nursing.
Five years of clinical experience; recent experience in utilization review, case management, patient navigation, or discharge planning is strongly preferred.
Familiarity with InterQual™ care management criteria.
Strong knowledge of utilization review, healthcare finance, and relevant payer requirements.
Strong analytical and interpersonal skills, with the ability to communicate daily with healthcare professionals, patients, and families.
Collaborative communication approach suited to working with diverse healthcare providers, insurers, patients, and families.
Knowledge and skills necessary to provide care across the life span, considering aging processes, human development stages, and cultural patterns.
Proficiency with Microsoft Office software, including email and Outlook calendar, and basic keyboarding skills.

Nice To Haves

Master’s degree in Nursing preferred.
Certified Professional in Healthcare Management (CPHM) is highly desirable.

Responsibilities

Apply InterQual™ level-of-care screening criteria to admissions within one business day and work with the team and physicians to resolve discrepancies and ensure accurate documentation.
Discuss cases that do not meet level-of-care criteria with the attending physician and develop a plan of action.
Review admissions and provide clinical information to third-party payers to support the level of care; act as a liaison with payers to clarify level-of-care questions.
Review Medicare admissions daily and conduct concurrent reviews at least every three days to support patient throughput and identify delays.
Deliver Hospital Issued Notice of Non-coverage (HINN) to Medicare beneficiaries when inpatient admission is not medically necessary or care could be provided in an alternative setting.
Initiate and complete concurrent expedited patient appeals, inform patients of insurers’ responses, and counsel them about the appeal process and care options.
Educate healthcare team members about Medicare and regulatory guidelines, appropriate levels of care, HINN delivery, and patient appeals.
Coordinate with the Care Coordination Manager regarding patients’ discharge readiness.
Identify opportunities to improve patient flow and reduce service and discharge delays through problem resolution and follow-up; track patient delays.
Promote patient satisfaction by supporting service authorizations and conducting expedited appeals of denied services with the patient’s physician of record.
In the Emergency Department, ensure the appropriate level of care is assigned upon admission, identify Medicare beneficiaries who require HINNs, deliver required notices, and advise patients about appeal rights and care options.