RN- Health Care (Full-Time

RN Utilization Management (RN UM) Overview
The RN Utilization Management (RN UM) functions as a support liaison for a variety of UM functions which may include the e‑TAR process, denials management, and the UM process. Coordinates care submission relating to the process of health‑care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with the finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determines medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.

Daily coordination of support documents pertaining to the DNFB List of Medi‑Cal patients.

Reports e‑TAR support progress and delays to Manager or Director of care management.

Participates in interdisciplinary team and department of revenue meetings to discuss e‑TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.

collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner.

Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.

Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (II) assure quality of care throughout the hospital stay, and (III) minimize adverse outcomes.

Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.

Patient needs are supported within the limitations of the existing individual beneficiary care structure.

Communicates relevant elements of the health plan benefits.

Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.

Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.

Adheres to the Care Management Department policies and procedures.

Participates in the Quality and Performance Improvement Plan for the Care Management Department.

Considers the patient population served, age‑specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.

Collaborates with on‑site care management team to support best practice guidelines.

Attends unit/department staff meetings as well as other meetings as assigned.

Maintain and complete Compass program training as assigned.

Associates Degree in Nursing required. Minimum 3-5 years recent experience in Case Management or Utilization Management or Prior Authorization.

Current California Registered Nurse License. Certification in UM or CM is highly preferred.

Confidence to communicate and outreach to other community health care organizations and personnel. Bilingual language skills preferred (Spanish). Basic computer skills.

Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability, genetic information, citizenship status, military service, or any other status protected by federal, state, or local laws.
MLK Community Healthcare