Inpatient Utilization Management Specialist

4 weeks ago

Oakland, California, United States Allameda Alliance for Health Full time
Job Summary

We are seeking a highly skilled Inpatient Utilization Management Reviewer to join our team at the Alliance. As a key member of our Utilization Management department, you will play a critical role in ensuring that our members receive the most appropriate and cost-effective care possible.

Key Responsibilities
  • Conduct thorough reviews of inpatient admissions to ensure medical necessity and appropriateness of care
  • Collaborate with hospitals, primary care providers, and specialists to develop and implement effective care plans
  • Utilize clinical judgment to assess and stratify members for appropriate levels of care and refer to Case and Disease Management as needed
  • Identify opportunities for discharge or transfer to lower levels of care and coordinate with hospital staff and vendors to facilitate transitions
  • Communicate effectively with internal stakeholders, including the Medical Director, to validate patient acuity and plan of care
  • Participate in daily and weekly grand rounds to stay up-to-date on best practices and share knowledge with colleagues
  • Process and review prior authorization requests for facility admissions, home health services, Durable Medical Equipment, and out-of-area services
  • Reconcile daily hospital census reports and face sheets against authorizations
  • Provide exceptional customer service and support to internal and external stakeholders
Requirements
  • Active California Registered RN license or Physicians Assistant or Nurse Practitioner required
  • One year experience in managed care or healthcare setting preferred
  • Excellent verbal and written communication skills
  • Ability to work independently and as part of a team
  • Strong critical thinking and problem-solving skills
  • Working knowledge of managed care, RVS, CPT, ICD-9, ICD-10, and CPT 4
What We Offer

We offer a competitive salary range of $105,853.04-$158,779.55 annually, as well as a comprehensive benefits package and opportunities for professional growth and development.

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best-qualified person in every job.

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