Registered Nurse Utilization Review

Job Summary:

The Registered Nurse in Utilization Review is responsible for managing and evaluating patient care within acute hospital and ambulatory settings to ensure appropriate utilization of healthcare services. This role involves conducting admission criteria assessments, benefits eligibility reviews, care coordination, concurrent and continued stay reviews, and determining medical necessity following evidence-based guidelines. The RN collaborates with interdisciplinary teams and uses regulatory and coding standards such as InterQual, CPT, ICD-10, and CMS guidelines to support utilization management and compliance. Responsibilities:

• Conduct admission criteria and benefits eligibility assessments for acute hospital and ambulatory patients.
• Perform care coordination and utilization reviews including concurrent, continued stay, pre-certification, prior authorization, and retrospective reviews.
• Determine medical necessity based on evidence-based guidelines and InterQual criteria.
• Utilize CPT coding, ICD-10 coding, and DRG groupings in review processes.
• Ensure compliance with regulatory standards including CMS, Department of Health, HIPAA, The Joint Commission, Core Measures, and National Safety Goals.
• Manage utilization review activities for various specialties including Emergency Department, ICU, MS ICU, Pediatrics, PICU, SDU/PCU/IMC/Obs, Surgical Services, and Women's Services.
• Support disease management and plan of care reviews.
• Perform remote utilization review tasks as needed.
• Maintain accurate documentation and reporting for utilization management activities.

Required Skills & Certifications:

• Active Registered Nurse license in California.
• Minimum of 2 years acute hospital experience in relevant specialties such as Emergency Department, ICU, Pediatrics, Surgical or Women's Services.
• Strong knowledge of utilization review processes, medical necessity criteria, and case management.
• Proficient in InterQual criteria, CPT coding, ICD-10 coding, and DRG systems.
• Familiarity with CMS, Department of Health, HIPAA, The Joint Commission, and other regulatory requirements.
• Excellent communication and interdisciplinary collaboration skills.
• Ability to work independently and handle remote utilization review work.
• Basic computer skills; facility will provide laptop, keyboard, and mouse.

Preferred Skills & Certifications:

• Experience with California Medi-Cal and related healthcare programs.
• Knowledge of ambulatory care and case management software systems.
• Additional certifications in case management or utilization review.

Special Considerations:

• Position requires an active California RN license.
• Work may include remote utilization review tasks.
• Must adhere to HIPAA and all regulatory compliance standards.
• Experience with CMS and state-specific regulatory agencies is critical.

Scheduling:

• Standard work hours are 8:00 AM to 4:30 PM or 9:00 AM to 5:30 PM Pacific Standard Time.
• Work schedule is typically weekday daytime shifts.