Clinical Utilization Management Specialist

4 weeks ago


Artesia, California, United States PIH Health Full time
Job Summary

The Utilization Management (UM) RN at PIH Health plays a vital role in ensuring the efficient delivery of care to patients. This position involves performing utilization review activities, including precertification, to ensure the appropriate level of care and status throughout admission. The UM nurse is responsible for determining the medical necessity of requests by performing first-level reviews and preparing cases for Physician Advisor review. This role requires strong organizational skills, excellent communication skills, and the ability to work collaboratively with a multi-disciplinary team.

Responsibilities

* Perform utilization review activities, including precertification, to ensure the appropriate level of care and status throughout admission
* Determine the medical necessity of requests by performing first-level reviews
* Prepare cases for Physician Advisor review
* Work collaboratively with a multi-disciplinary team to manage the care of patients
* Ensure a process that is efficient for providing care, ensuring timely and appropriate levels of care for incoming 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
* Strong organizational skills, excellent communication skills, and the ability to work collaboratively with a multi-disciplinary team

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