Utilization Review RN

Prime Healthcare•Ontario, CA

19h•Onsite

About The Position

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0 million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Requirements

Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.
Minimum 3 years RN Utilization Manager working for a Health Plan.
At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals.
Current BCLS (AHA) certificate upon hire and maintain current.
Knowledge of MCG Criteria and/or InterQual Criteria required.
Experience and knowledge in basic to intermediate computer skills.

Nice To Haves

Five years acute care nursing experience preferred.
Experience with self-funded health plan preferred.

Responsibilities

Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO.
Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care.
The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.