RN Case Manager EX - Utilization Management Remote - Irvine

Who We Are

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health
- Orange, UCI Health
- Irvine, four Community Network hospitals and a growing network of ambulatory care centers across Orange and Los Angeles counties.

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health
- Orange, UCI Health
- Irvine, four Community Network hospitals and a growing network of ambulatory care centers across Orange and Los Angeles counties.

Incumbent is responsible for implementing the utilization management process for patients admitted to the hospital. Monitors and coordinates resource utilization throughout the health system and evaluates services provided. Performs inpatient admission and concurrent review functions utilizing medical staff-approved decision support criteria (Inter Qual Intensity of Service, Severity of Illness criteria). Reviews clinical documentation, communicates with physician and other clinical staff to ensure documentation accurately reflects the patient’s severity of illness, and collaborates with health plans/ payors by providing clinical information as required.

Analyzes and identifies utilization patterns and trends and participates in denial prevention and management, appeals, special studies, projects, audits, or routine utilization monitoring activities while ensuring compliance with applicable regulatory, payer and organizational requirements.

• Working knowledge of acute-care utilization management criteria and decision-support tools, including Inter Qual and/or MCG
• Proficient in Microsoft Office suite (Excel, Word, PowerPoint, Access)
• Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties.
• Must possess complete understanding of acuity levels for the adult patient population
• Must demonstrate customer service skills appropriate to the job
• Minimum 5 years of recent clinical experience (within the last 10 years) in an acute care adult setting and 1 year of previous Case Management, Utilization Management, or a related acute care coordination experience for the adult population.
• Knowledge of payer authorization and concurrent review processes, including submission of clinical information, continued-stay reviews, and communication with health plans and medical groups.
• Knowledge of denial prevention, denial management, retrospective review, appeals, and/or peer-to-peer processes preferred.
• Familiarity of Joint Commission, CMS, CDPH and CCS, Medicare, Medi Cal and commercial health plan requirements applicable to utilization management and hospital services
• Excellent written and verbal communication skills in English
• Demonstrated knowledge of utilization management principles, medical necessity, level-of-care determination, concurrent review, Inter Qual or other recognized clinical decision-support criteria, payer requirements, and denial prevention/management.
• Current RN License
• Computer literacy and proficiency
• Bachelor of Science Nursing Degree
• Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload
• Ability to establish and maintain effective working relationships across the Health System

• Knowledge of University policies and procedures
• CCM, ACM

• RN
• BLS

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