Utilization Review Nurse in Gardena, CA at Pipeline Health Los Angeles

Date Posted: 4/30/2021

Job Snapshot

Job Description

Memorial Hospital of Gardena

Job Title: Utilization Review Nurse 

City: Gardena / State: California    

Transfer Call Center

Shift Varied - 8 Hours

Varied Hours

.

                                      


Job Description and Job Responsibilites

Job Title: Utilization Review Nurse

Job Summary: 

The Utilization Review Nurse is responsible for rapid medical necessity review of patients being directly admitted through the Pipeline Transfer Center (PTC), and of inpatients at Pipeline facilities when assigned.  The Utilization Review Nurse will assure, in collaboration with the IPA and referring facilities, that the right care is provided at the right place, at the right time. This goal is accomplished by using established criteria to evaluate the appropriateness of admission, level of care needed and/or readiness for discharge.

Essential Job Duties:                                                         

  • Initiate the intake and utilization review process using InterQual criteria.
  • Interfaces with community physicians and referring facilities to gather clinical data needed to determine medical necessity and level of care.
  • Respond immediately to telephonic requests from PTC for medical necessity reviews. Provide prompt feedback to PTC re: clearance to admit patient if meeting IP criteria.
  • Position requires remote and occasional on-site performance.
  • Gatekeeping for the appropriateness of the admission of the patients to the Pipeline hospital system.
  • Serves as a role model for the Mission, Vision and Values of the organization and fulfills other job duties as requested.
  • Utilize critical thinking skills and clinical knowledge to assess patient’s medical necessity needs.
  • Knowledge of healthcare reimbursement systems: HMO, PPO, capitated agreements, and PPS.
  • Must be able to effectively communicate with, and promote cooperation and collaboration among patients/families, physicians, nurses, emergency departments, community resources and social workers.
  • Must be able to develop an organized work plan in a high-volume environment with rapidly changing priorities.
  • Must possess leadership, autonomy, delegation and supervisory skills to influence the interdisciplinary team to achieve admission to the appropriate facility and level of care.
  • Must have strong clinical assessment skills necessary to provide utilization review and transition planning services to meet the patients’ complex medical, emotional and social needs.
  • Must be self- directed and organized with the ability to independently prioritize and follow through to achieve desired clinical, satisfaction and financial outcomes.

Job Requirements

Education/Experience:

  • CCM or ACM desired, but not a requirement.
  • Minimum of 2 years in utilization review and case management.
  • Strong InterQual skills required

Licensure/Certifications:

  • Current RN licensed in good standing by the California Board of Nursing
  • Current BLS for Health Care Provider