Nurse Utilization Manager

3 days ago


Pasadena, Texas, United States PIH Health Full time
Job Summary

We are seeking a highly skilled and experienced Registered Nurse to join our Utilization Management team at PIH Health. As a Utilization Management RN, you will play a critical role in ensuring that patients receive the most appropriate level of care, while also promoting efficient and effective use of healthcare resources.

Key Responsibilities
  • Perform utilization review activities, including precertification, to ensure that patients receive the most appropriate level of care.
  • Conduct initial reviews, concurrent reviews, and retrospective reviews to determine medical necessity and ensure compliance with guidelines.
  • Collaborate with a multi-disciplinary team to manage patient care and promote efficient use of healthcare resources.
  • Prepare cases for Physician Advisor review and delegate tasks to LVNs as needed.
  • Develop and implement effective case management plans to ensure timely and appropriate levels of care for patients.
Requirements
  • Current licensure as an RN in the state of California.
  • A minimum of 2 years of bedside nursing experience in an acute care setting.
  • A minimum of 2 years of case management experience.
  • Knowledge of payer requirements and Milliman Care Guidelines (MCG).
  • Preferred: Certified Case Manager or Accredited Case Manager, BSN, and experience with electronic systems.
About PIH Health

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County, and San Gabriel Valley region. We are committed to providing high-quality patient care and promoting a culture of excellence and innovation.



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