Utilization Management RN

Job Summary and Responsibilities

As our UM RN (Utilization Management Registered Nurse), you will be responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making, as it relates to the application of criteria and composition of compliant denial notices, to review medical records, authorize requested services, and prepare cases for physician review based on medical necessity.Every day you will partner with both the Pre-Service and In-Patient Utilization Management teams. You will ensure to monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity, and cost-effectiveness. This involves meticulous review of medical records, application of clinical guidelines, and collaborative communication to facilitate optimal patient care while ensuring compliance and fiscal responsibility.To be successful in your role, you will strategically ensure the integrity and accuracy of utilization management decisions, meticulously reviewing medical records and applying clinical criteria to determine medical necessity. You will demonstrate exceptional clinical judgment, partner effectively with pre-service and in-patient teams, and maintain rigorous oversight of care appropriateness, quality, continuity, and cost-effectiveness, thereby safeguarding both patient well-being and organizational resources.

 

As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

This position is remote with a CA RN license.  PST business hours will be expected.

Potential for on-call, weekend and holiday shifts.

• Reviews designated requests for referral authorizations either proactively, concurrently or retroactively. Gathering all information needed to make a determination and/or coordinate with the Medical Director as needed.
• Ensure compliance with turnaround times and accuracy standards are met.
• Ensure contracted providers are in place when authorizing.
• Responsible to coordinate with contracting to obtain appropriate contracts as deemed appropriate.
• Identify cases that require additional case management.
• Work with appropriate departments and internal staff to coordinate patient care

Job Requirements

Required

• Three (3) years recent clinical experience
• Graduate of an accredited RN program
• Clear and current CA Registered Nurse (RN) license
• Knowledge of nursing theory and ability to apply or modify as appropriate
• Knowledge of ICD-10, CPT, HCPCS coding, medical terminology and insurance benefits
• Knowledge of legal and ethical considerations related to patient information, PHI and HIPPA regulations

Preferred

• Bachelors of Nursing (BSN) preferred
• Previous inpatient Utilization Management (UM) experience strongly preferred
• Experience with MCG strongly preferred
• EZCap experience a plus

Where You’ll Work

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

 

One Community. One Mission. One California