Cedars-Sinai Registered Nurse - Utilization Review Case Manager in Los Angeles, California
Are you ready to bring your expert clinical skills to a world-class facility recognized as one of the top ten in the United States? Do you have a passion for the highest quality and patient happiness? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you.
When the work you do every single day has a crucial impact on the lives of others, every effort, every detail, and every second matters. This shared culture of happiness, passion and dedication pulses through Cedars-Sinai, and it’s just one of the many reasons we’ve achieved our fifth consecutive Magnet designation for nursing excellence. From working with a team of dedicated healthcare professionals to using state-of-the-art facilities, you’ll have everything you need to do something incredible—for yourself, and for others. Join us, and discover why U.S. News & World Report has named us one of America’s Best Hospitals.
Summary of Essential Duties:
Validate patients' placement to be at the most appropriate level of care based on nationally accepted admission criteria
Use medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay
Secure authorization for clinical services through timely collaboration and communication with payers as required
Follow the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review
Collaborate with Care Coordinators to identify and follow up on Observation class patients
Follow up with the payer to verify approval/authorization of the hospital stay (all dates of services)
Function as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to ensure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization
Graduate of an accredited nursing program required
Current, unrestricted California RN license required
American Heart Association or American Red Cross BLS required
A minimum of 3 years of acute care nursing experience required
2+ years of case management experience preferred
Knowledge of medical literature, research methodology, health care delivery systems and financial reimbursement required
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.