Career Center

The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer. The RN Utilization Management Specialist confers and reviews with physicians on medical admitting information to assess medical necessity and uses evidence-based criteria to consider the anticipated length of stay, level of care, intensity of service to support access to services. The RN Utilization Management Specialist facilitates timely transmission of admission, concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented. Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system.

Essential Duties:

• Validates patient registration status with physician order against medical necessity screening criteria
• Applies evidence based medical necessity screening criteria as defined by the Utilization Review plan.
• Performs admission, continued stay and discharge reviews.
• Reviews daily surgery schedule for planned admissions to ensure that services are screened for appropriate level of care status.
• Ensures that all bedded outpatient services that require admit to hospital are screened for appropriate level of care status.
• Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan.
• Follow up on all payer authorization determinations to ensure completion prior to closure of record.
• Notifies medical physician advisor when patient’s medical condition does not meet admission or continued stay criteria as defined by 42 CFR 428.30 and/or health plan.
• Coordinate and facilitate concurrent Peer – to – Peer calls as needed.
• Adheres to regulatory procedures: MOON, IMM Discharge, Appeal/HINN, Code 44, Two Midnight Rule, Inpatient Only Procedure.
• Responds timely to payer requests for clinical reviews and completes verbal reviews as needed, including the TAR process as defined department protocol.
• Communicates with payers when patient status changes from observation/extended recovery to inpatient to obtain authorization for inpatient stay.
• Initiates a call to payers to confirm receipt of clinical reviews and request authorization of all days upon discharge.
• Documents communication with payers and outcomes of discussions in electronic systems.
• Inputs authorization data into spreadsheets per protocol.
• Assists with denial management to identify opportunities to improve department processes
• Represents the department in a positive and professional manner
• Demonstrates collaborative working relationships with case managers and payers to ensure authorizations are obtained and current.
• Maintains awareness of payer/reimbursement practices and requirements.
• Identifies opportunities to improve department workflow and process regarding payer communication.
• Identifies compliance and ethical issues and reports appropriately.
• Assists with orientation of new staff.
• Participates in hospital quality improvement processes and helps identifies opportunities to improve care.
• Identifies and documents avoidable delays in the electronic system.
• Strives to support and contribute to the success of the departments outcome metrics, key performance indicators and /or departmental goals and objectives.
• Documents outcomes in the medical record.
• Adheres to hospital and departmental protocols, workflows, policies, procedures, standards and competencies for clinical role
• Adheres to the mission, vision and values of the organization.
• Performs other duties as requested/assigned.
   

Required Qualifications:

• Req Bachelor's degree Nursing BSN

• Req 3 years Clinical experience.
• Req 3 years Case management experience in an acute care hospital setting
• Req 1 year Experience utilizing InterQual Criteria in CERME format.

• Req Must have excellent communication skills, including the ability to speak, read and write English proficiently.
• Req Knowledge of medical procedures and conditions and ability to understand, follow and successfully perform duties, including whole blood collection, and apheresis procedures, in accordance with administrative and clinical policies, regulations and procedures.

Preferred Qualifications:

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

Logo

About University of Southern California (USC)

USC is the leading private research university in Los Angeles—a global center for arts, technology and international business. With more than 47,500 students, we are located primarily in Los Angeles but also in various US and global satellite locations. As the largest private employer in Los Angeles, responsible for $8 billion annually in economic activity in the region, we offer the opportunity to work in a dynamic and diverse environment, in careers that span a broad spectrum of talents and skills across a variety of academic and professional schools and administrative units. As a USC employee and member of the Trojan Family—the faculty, staff, students, and alumni who make USC a great place to work—you will enjoy excellent benefits, including a variety of well-being programs designed to help individuals achieve work-life balance.

Connections working at University of Southern California (USC)