CA
Position Title:
Utilization Management Nurse RN I
Job Overview:
The Utilization Management Nurse RN I is responsible for clinical review of inpatient care, ensuring medical necessity and appropriateness of admissions and ongoing confinement. The role involves the use of clinical guidelines and Medicaid criteria to make first-level approval determinations, with referrals for second-level review when necessary. This position requires independent work, though support may be needed for more complex cases. Frequent communication with members, caregivers, medical providers, and staff is part of the role.
Essential Duties and Responsibilities:
Conduct clinical inpatient reviews (prospective, concurrent, and retrospective).
Collaborate with hospital staff and providers for efficient discharge planning.
Start discharge planning at admission and work with discharge planners and case managers.
Refer cases to Case Management and Disease Management programs when necessary.
Ensure all clinical documentation is up to date for accurate daily census reports.
Collaborate with Social Workers when social interventions are required.
Communicate with the Medical Director as needed for case reviews.
Serve as a liaison to community providers and members.
Act as a preceptor to new staff.
Make first-level approval determinations when criteria are met.
Identify and refer cases for quality of care, coordination of benefits, and third-party liability issues.
Present cases and rationale to the Medical Director for potential denial determinations.
Perform retrospective reviews and update authorizations in the claims system.
Maintain a performance level of 85% or higher on audits.
Perform other related duties as assigned.
Core Competencies/Knowledge & Skill Requirements:
Commitment to patient advocacy and fostering a positive, respectful work environment.
Strong knowledge of acute and chronic care nursing principles, medical terminology, and treatments.
Proficient in ICD10/CPT coding and medical record evaluation.
Ability to work independently, prioritize tasks, and communicate effectively.
Strong interpersonal skills and the ability to maintain confidentiality.
Basic skills in Word, Excel, and database navigation.
Ability to work in a team environment and handle sensitive situations with tact and diplomacy.
Attention to detail and ability to complete tasks in a timely manner.
Employment Standards:
Active, current, unrestricted Registered Nurse license.
Minimum of 2 years of full-time clinical experience in acute care, community health, public health, or chronic disease management.
Experience in case management or care coordination preferred.
Familiarity with MCG Clinical guidelines, Medi-Cal, and California Children’s Services is a plus.
Knowledge of local community resources for seniors and individuals with disabilities is a plus.
Bachelor's Degree in Nursing, Health Administration, or related field preferred.
Commitment to Diversity: As an equal opportunity employer committed to meeting the needs of a multi-generational and multicultural workforce, Key Staffing recognizes that a diverse staff, reflective of our community, is an integral and welcome part of a successful and ethical business. We hire local talent at all levels regardless of race, color, religion, age, national origin, gender, gender identity, sexual orientation, or disability and actively foster inclusion in all forms both within our company and across interactions with clients, candidates, and partners.
If this position caught your eye, send us your resume! For best consideration, include the job title and source where you found this position in the subject line of your email to knegrete@hirekeystaff.com.