Providence Health & Services RN Utilization Management in Santa Monica, California
Providence is calling a RN Utilization Management (Full Time/Day Shift) for Providence Saint John's Health Center.
This position works remotely, and every 3rd weekend and holiday rotations.
Apply today! Applicants that meet qualifications will receive a text with additional questions from our MODERN HIRE screening and interview system.
Please upload a current resume reflecting all relevant experience.
We are seeking a RN Utilization Management who will provide prospective, retrospective and concurrent utilization review for our LA ministries. Provide clinical reviews and medical records daily during admission for all payers as required by the health plans. Requires a strong clinical background blended with a well-developed knowledge and skills in Utilization Management, medical necessity and patient status determination.
The UM nurse effectively and efficiently manages a diverse workload in a fast paced, rapidly changing regulatory environment with excellent negotiation, communication, problem solving and decision making skills.
In this position you will:
Review the Electronic Medical Record to perform admission reviews and continued stay reviews utilizing Interqual criteria to determine medical appropriateness of the initial admission and the continued stay. Faxes via EPIC clinical reviews and clinical documentation to payers daily to demonstrate medical necessity for the hospital stay
Admission reviews are conducted within one business day of admission
Continued stay reviews are provided daily for all HMO and Commercial payers
Continued stay reviews are provided as directed by the Director, Utilization Management and Appeals
Continued stay reviews are provided upon admission until the patient meets Acute IP LOC OR a secondary reviewer deems patients requires acute IP care for all Medi-Cal FFS beneficiaries
Daily clinical reviews will be documented for all pending and restricted Medi-Cal patients
Serve as a resource for California ministries
Focus on patient class determination and escalates all cases with a patient class mismatch
Perform continued stay reviews on current patients and communicates clinical information to payers in a timely manner such that the patient’s hospital days are authorized at the level of care being provided
Collaborate with clinical leadership to develop a proactive approach to meeting clinical documentation standards
Interpret and communicate regulatory standards and their implications to key stakeholders as appropriate
Collaborate with ministries as appropriate in developing solutions to support clinical documentation improvement due to audit findings
Proactively identify opportunities to improve care management related to medical necessity
Escalate issues proactively, using sound judgment to determine the need for escalation
Participate in a culture where fellow team members are focused on their contribution, and opportunity to impact the patient experience
Management of denials while patients are in hospital to ensure peer to peer physician reviews are completed to prevent denials
Identify, report cases and problems appropriate for secondary review to Director or Physician Advisor
Advocate for appropriate provider documentation to accurately reflect patient severity of illness and risk. Collaborates with CDI
Maintain collaborative relationships with providers, care management staff in the ministries, revenue cycle team and outside payers
Participate in the development, implementation, evaluation and ongoing revision of initiatives to improve quality, continuity and cost effectiveness
Provide clear and thorough documentation based on established standard work
Provide orientation and mentoring to new staff
Demonstrate ability to conduct age specific reviews for all age groups
Pass Interqual IRR annually with a score of 90% or higher
Associate's Degree in Nursing
Current RN license
1 year experience working in a remote UR environment - OR - 3 years experience working as an acute hospital case manager
Thorough knowledge of principles and practice of health care is required
Excellent writing skills are required
Through knowledge of evidence-based practices is required
Requires excellent organizational and analytical skills with strong abilities for independent decision making and problem solving
Requires excellent communication skills to interdisciplinary team
Bachelor's Degree or Master's Degree in Nursing
Case management certification
Working knowledge of regulations and provider contracts governing coverage of inpatient services (e.g., Medicare, Medi-Cal, Commercial Payers)
About the hospital you will serve.
Providence Saint John’s Health Center in Santa Monica, California, is part of Providence Health & Services, an integrated, not-for-profit network of hospitals, care centers, medical clinics, home health services, affiliated services and educational facilities in the western United States. Founded in 1942, Providence Saint John’s Health Center enjoys a reputation for clinical excellence across many disciplines. The 266-bed health center has a medical staff of more than 900 physicians, 1,800 employees and a host of volunteers who share a commitment to providing quality care for all.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Location: California-Santa Monica
Req ID: 309782