Utilization Management RN

HCA Healthcare • Campbell, CA

404d • $87,152 - $130,770

About The Position

The Utilization Management RN at HCA Healthcare is responsible for ensuring timely reviews of referral requests, procedures, and pre-certification requests in accordance with established policies. This role involves applying clinical criteria to authorization requests, conducting concurrent reviews, and maintaining performance standards while keeping the UM Manager informed of any member or provider issues. The position requires a strong focus on patient interactions and the application of case management skills for high-risk members.

Requirements

• Current California RN or LVN license required.
• Minimum three to five years of experience in Managed Care, Provider Office, or Utilization Review organization required.
• Knowledge of Commercial, Medicare, and Medi-Cal HMO lines of business.
• Knowledge of medical coding practices.
• Working knowledge of medical standards of practice or experience with using UM medical criteria (i.e. Milliman and InterQual) required.
• Strong computer experience including using the internet to research clinical and non-clinical issues required.

Responsibilities

• Review authorization requests applying clinical criteria based on nationally standardized guidelines and UM criteria.
• Prepare and present authorization requests with supporting documentation for review with the Medical Director.
• Ensure timely reviews of authorization requests in accordance with written policy, regulatory, and Health Plan guidelines.
• Apply case management skills to members identified as high risk for hospital readmissions through telephonic case management.
• Perform other duties as assigned.

Benefits

• Employee stock purchase plan
• Disability insurance
• Health insurance
• Dental insurance
• Flexible spending account
• Tuition reimbursement
• Paid time off
• Adoption assistance
• Family leave
• Vision insurance
• 401(k) matching
• Pet insurance

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: No Education Listed