Registered Nurse - Utilization Management - Los Angeles, CA

Utilization Review Case Manager

The Utilization Review Case Manager is responsible for assessing the medical necessity, appropriateness, and efficiency of patient care services. Utilizing evidence-based clinical criteria such as InterQual, MCG, and the CMS Two-Midnight Rule. The UR Case Manager performs initial, concurrent, and retrospective reviews to ensure accurate patient status, appropriate level of care, and optimal length of stay. In this role, the UR Case Manager collaborates closely with physicians, care coordinators, payers, and the interdisciplinary care team to secure timely authorizations, optimize utilization of hospital resources, and support high-quality, patient-centered outcomes. The UR Case Manager proactively identifies barriers to discharge, monitors patient progression, and helps reduce denials through precise documentation and effective communication. The incumbent requires strong clinical judgment, critical thinking, and communication skills, along with the ability to work both independently and collaboratively in a fast-paced, multidisciplinary environment. Serving as a key liaison between the clinical team and payers, the UR Case Manager plays a vital role in ensuring regulatory compliance, appropriate reimbursement, and safe, efficient, patient-centered care.

Responsibilities:

• Utilizes InterQual, MCG, and CMS Two-Midnight Rule guidelines to assess and determine the appropriate level of care, escalating cases as needed to the UM Medical Director, UM Physician Advisor, or external physician reviewer (e.g., R1) in accordance with departmental escalation policies.
• Uses clinical knowledge and nursing expertise to conduct initial and concurrent reviews for inpatient, observation, and outpatient/procedural services in alignment with department guidelines, ensuring documentation accurately reflects severity of illness and intensity of service to support reimbursement.
• Partners with physicians, care coordinators, and the interdisciplinary team to support accurate patient classification, appropriate care progression, and timely transitions of care.
• Verifies physician orders in the medical record to ensure compliance with Medicare, Medicaid, and other payer guidelines for determining the appropriate level of care and consult with physicians as needed to clarify or update orders.
• Advocates for securing payer or other reimbursement resources for uninsured and underinsured patients.
• Communicates effectively with third-party payers, providing timely and accurate clinical information in accordance with payer and departmental guidelines.
• Tracks and secures payer authorizations for all dates of service and follows up proactively to prevent lapses in coverage.
• Reviews and works to overturn concurrent denials; assists with appeals preparation and facilitate peer-to-peer discussions as indicated.
• Monitors patient length of stay and care progression to ensure appropriate resource use, resolves barriers, and advocates for safe, efficient, and financially appropriate care, escalating cases in accordance with departmental guidelines.
• Identifies and documents avoidable delays and barriers to patient flow, escalating unresolved issues through appropriate channels in accordance with departmental chain of command and escalation guidelines.
• Maintains confidentiality and ensures compliance with all regulatory, payer, and organizational policies.
• Maintains accurate, complete, and timely documentation per department standards.