Case Manager Utilization Specialist

3 weeks ago

San Francisco, California, United States University of California , San Francisco Full time
Job Summary

The Utilization Management Nurse Specialist is responsible for the appeal process for the inpatient adult population and is an active participant of the Medicare one day stays process. The incumbent works in a collaborative relationship with admitting, patient financial services, physicians, nurses, case managers and social workers of the interdisciplinary team to collect information to support appeals. Demonstrates the ability to work with any patient regardless of race, gender, religious affiliation, cultural beliefs, lifestyle, and disease process or treatment plan. The final salary and offer components are subject to additional approvals based on UC policy. Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement. The salary range for this position is $ Hourly Rate. To learn more about the benefits of working at UCSF, including total compensation, please visit: Required Qualifications
  • Possesses a bachelor's degree in healthcare related field and two years of Case Management, Utilization Management or Utilization Review work experience.
  • Completed an InterQual training course
  • Ability to use sound judgment in responding to issues and concerns.
  • Solid communication and interpersonal skills to communicate effectively with all levels of staff verbally and in writing.
  • Solid organizational skills and ability to multi-task with demanding timeframes.
  • Working knowledge of common organization-specific and other computer application programs.
  • Ability to use discretion and maintain confidentiality.
  • Demonstrates ability to take direction from multiple team members.
  • Self-directed with the ability to prioritize and adapt to a high-volume changing environment.
  • Assertive and creative in problem solving while functioning as an active team member.
  • Strong customer service skills to coordinate service delivery including attention to members/customers, sensitivity to concerns, proactive identification and resolution of issues to promote positive outcomes for members.
  • Ability to type minimum 45 wpm using a QWERTY keyboard.
  • Superior Knowledge of medical terminology.
  • Skilled in the operation of computers including strong working knowledge of Microsoft Outlook, Microsoft Word, and Microsoft Excel.
  • Must have working knowledge of CMS Medicare guidelines (including two midnight rule, NCDs, LCDs, Code44, Part B Rebilling and the IP only list) and able to apply those guidelines in the process of reviewing admission reviews.
  • Proficient in completing accurate chart reviews using the InterQual or MCG evidence-based clinical decision support solution for initial and concurrent.
  • Strong writing skills that include the ability to generate persuasive arguments (appeals) supporting the services provided to our patients against any health plan denial.
Preferred Qualifications
  • Master's degree in healthcare
  • InterQual Certified Instructor
  • National healthcare certification
Equal Employment Opportunity The University of California San Francisco is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Department Description The UCSF Health Utilization Management Department is part of the multidisciplinary team of expert clinicians and staff, who continually strive to provide proactive and patient centered access to care and resources along the healthcare continuum. The Utilization Management Department evaluates the efficiency, appropriateness and medical necessity of treatments, services, procedure, and facilities provided to patients on a case-by-case basis. About UCSF At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team. Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents. Pride Values UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values. In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at

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