About this opportunity
UC Irvine lists this RN Case Manager EX - Utilization Management - Days - Remote - Irvine opportunity in irvine, California. Review the employer’s description below for duties, qualifications and application requirements.
Job description
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.
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.
Your Role on the Team
Position Summary
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 (InterQual 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.
Required Qualifications
What It Takes to be Successful
Working knowledge of acute-care utilization management criteria and decision-support tools, including InterQual 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, InterQual 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
Preferred Qualifications
Knowledge of University policies and procedures
CCM, ACM
Licenses And Certifications
RN
BLS
Education
Total Rewards
We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.
Conditions Of Employment
The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:
Background Check and Live Scan
Employment Misconduct*
Legal Right to Work in the United States
Vaccination Policies
Smoking and Tobacco Policy
Drug Free Environment
Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.
California Child Abuse and Neglect Reporting Act
E-Verify
Pre-Placement Health Evaluation
Details of each policy may be reviewed by visiting the following page:
Closing Statement
The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy.
We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.
UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at or at , Monday - Friday from 8:30 a.m. - 5:00 p.m.
Consideration for Work Authorization Sponsorship
Must be able to provide proof of work authorization
#J-18808-Ljbffr
Worksite address
irvine, CA, 92713, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.