Job Description

Job Summary:

The Registered Nurse in Utilization Review is responsible for evaluating and coordinating patient care in acute hospital and ambulatory settings. This role involves assessing medical necessity, conducting admission, concurrent, and continued stay reviews based on evidence-based guidelines and InterQual criteria. The nurse will collaborate with case management teams to ensure compliance with regulatory standards including CMS, HIPAA, and The Joint Commission. Strong knowledge of CPT coding, billing, and DRG is essential, along with experience in acute hospital specialties such as ICU, MSP, and Pediatrics. The position requires a California RN license and offers a structured daytime schedule.

Responsibilities:

• Perform utilization review activities including admission criteria assessment, concurrent review, and continued stay reviews.
• Determine medical necessity using evidence-based guidelines and InterQual criteria.
• Conduct pre-certification, prior authorization, and retrospective review processes.
• Collaborate with case management and care coordination teams to develop and review patient plans of care.
• Apply knowledge of CPT coding, billing, and DRG systems to support review activities.
• Ensure compliance with CMS, Department of Health, HIPAA, and The Joint Commission standards.
• Utilize disease management principles to support patient care decisions.
• Maintain thorough documentation and communication with interdisciplinary teams.
• Use provided laptop, keyboard, and mouse to complete remote and onsite work efficiently.

Required Skills & Certifications:

• Active Registered Nurse license in California.
• Minimum 2 years acute hospital experience, preferably in ICU, MSP, or Pediatrics.
• Strong knowledge of utilization review processes and medical necessity criteria.
• Experience with CPT coding, billing, and DRG systems.
• Familiarity with CMS, HIPAA, The Joint Commission, and other regulatory requirements.
• Ability to interpret and apply InterQual criteria.
• Proficient in case management and care coordination.
• Excellent communication and interdisciplinary collaboration skills.

Preferred Skills & Certifications:

• Experience with Medi-Cal and California-specific healthcare regulations.
• Prior experience in remote utilization review work.
• Knowledge of pediatric and ICU specialty care.
• Familiarity with national safety goals and core measures.

Special Considerations:

• Must hold a valid California RN license.
• Work involves compliance with strict regulatory and privacy standards.
• Position includes use of facility-provided technology equipment.
• May require occasional remote work capabilities.

Scheduling:

• Standard work hours are 8:00 AM to 4:30 PM or 9:00 AM to 5:30 PM Pacific Standard Time.
• Day shift schedule with no specified on-call requirements.

Job Tags

Casual work, Remote work, Day shift

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