Utilization Review Representative

CHOC • Orange, CA

9d • $29 - $49 • Onsite

About The Position

The Utilization Review Representative reviews utilization for inpatient and outpatient statuses and processes internal and external authorization requests with payors for treatments, services, and supplies, working in collaboration with inpatient and outpatient RN Care Managers. The representative may assist with the RN Care Manager’s caseload as assigned and supports data collection, insurance verification, financial counseling, and customer service. The role is responsible for ensuring work is accurate and complete across all areas of responsibility.

The position is based in Orange, California, and has a day shift of 8 hours. CHOC describes its work as providing exceptional and innovative pediatric care across hospitals, clinics, and practices, and states that its compensation, benefits, and career development programs are intended to support employees’ professional and personal goals.

Requirements

• At least 2 years of acute care or ambulatory care experience.
• Graduate of an accredited Licensed Vocational Nursing program.
• California Licensed Vocational Nurse (LVN) license.
• Basic Life Support (BLS) certification.
• Ability to work effectively under pressure amid changing priorities, interruptions, census changes, payor demands, and discharge-planning demands.
• Excellent interpersonal communication, conflict resolution, problem-solving, and negotiation skills.
• Clinical knowledge of multiple age groups, medical illnesses, and treatment plans according to disease process, diagnosis, and anticipated length of stay.
• Strong organizational and time-management skills, including the ability to multitask and prioritize.
• Ability to work independently and exercise sound judgment when interacting with physicians, payers, patients, and families.
• Ability to work collaboratively with people across social, economic, and cultural backgrounds.
• Computer skills using Microsoft Office, including Excel, Word, PowerPoint, and Access.
• Ability to meet required competencies upon completion of orientation and maintain annual departmental competency requirements.

Nice To Haves

• More than one year of nursing experience in an acute care or ambulatory setting.
• At least one year of pediatric nursing experience and prior experience as a Utilization Review nurse.
• Bachelor’s degree in nursing from an accredited university.
• Certification in Utilization Review and/or Case Management; Certified Pediatric Nurse (CPN).
• Knowledge of CCS/Medi-Cal regulations and requirements.
• Knowledge of third-party payor requirements to optimize reimbursement.
• Ability to apply pediatric severity-of-illness and intensity-of-service criteria to information extracted from clinical documentation.
• Knowledge of third-party payor methods.
• Bilingual ability.
• Pediatric Emergency Assessment, Recognition and Stabilization (PEARS).
• Comprehensive Crisis Management (CCM).

Responsibilities

• Review utilization for inpatient and outpatient statuses.
• Process internal and external authorization requests with payors for treatments, services, and supplies in collaboration with inpatient and outpatient RN Care Managers.
• Assist with the RN Care Manager’s caseload as assigned.
• Support data collection, insurance verification, financial counseling, and customer service.
• Ensure work is accurate and complete across all areas of responsibility.
• Communicate with third-party payors to obtain authorization for the appropriate treatment setting for patients requiring medical, psychiatric, and chemical dependency treatment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree