Providence Health & Services RN Utilization Management in Torrance, California
Providence is calling a RN Utilization Management (Full time/Day shift) for Providence Little Company of Mary Medical Center Torrance in Torrance, CA.
This position works remotely, Mon-Fri 9:00am-5:30pm, and every 3rd weekend rotation.
Apply today! Applicants that meet qualifications will receive a text with additional questions from our MODERN HIRE screening and interview system.
Please upload a current resume reflecting all relevant experience.
We are seeking a RN Utilization Management who will provide prospective, retrospective and concurrent utilization review for our LA ministries. Provide clinical reviews and medical records daily during admission for all payers as required by the health plans. Requires a strong clinical background blended with a well-developed knowledge and skills in Utilization Management, medical necessity and patient status determination.
The UM nurse effectively and efficiently manages a diverse workload in a fast paced, rapidly changing regulatory environment with excellent negotiation, communication, problem solving and decision making skills.
In this position you will:
Review the Electronic Medical Record to perform admission reviews and continued stay reviews utilizing Interqual criteria to determine medical appropriateness of the initial admission and the continued stay. Faxes via EPIC clinical reviews and clinical documentation to payers daily to demonstrate medical necessity for the hospital stay
Admission reviews are conducted within one business day of admission
Continued stay reviews are provided daily for all HMO and Commercial payers
Continued stay reviews are provided as directed by the Director, Utilization Management and Appeals
Continued stay reviews are provided upon admission until the patient meets Acute IP LOC OR a secondary reviewer deems patients requires acute IP care for all Medi-Cal FFS beneficiaries
Daily clinical reviews will be documented for all pending and restricted Medi-Cal patients
Serve as a resource for California ministries
Focus on patient class determination and escalates all cases with a patient class mismatch
Perform continued stay reviews on current patients and communicates clinical information to payers in a timely manner such that the patient’s hospital days are authorized at the level of care being provided
Collaborate with clinical leadership to develop a proactive approach to meeting clinical documentation standards
Interpret and communicate regulatory standards and their implications to key stakeholders as appropriate
Collaborate with ministries as appropriate in developing solutions to support clinical documentation improvement due to audit findings
Proactively identify opportunities to improve care management related to medical necessity
Escalate issues proactively, using sound judgment to determine the need for escalation
Participate in a culture where fellow team members are focused on their contribution, and opportunity to impact the patient experience
Management of denials while patients are in hospital to ensure peer to peer physician reviews are completed to prevent denials
Identify, report cases and problems appropriate for secondary review to Director or Physician Advisor
Advocate for appropriate provider documentation to accurately reflect patient severity of illness and risk. Collaborates with CDI
Maintain collaborative relationships with providers, care management staff in the ministries, revenue cycle team and outside payers
Participate in the development, implementation, evaluation and ongoing revision of initiatives to improve quality, continuity and cost effectiveness
Provide clear and thorough documentation based on established standard work
Provide orientation and mentoring to new staff
Demonstrate ability to conduct age specific reviews for all age groups
Pass Interqual IRR annually with a score of 90% or higher
Associate's Degree in Nursing
Current RN nurses license in good standing from any State
1 year experience working in a remote UR environment or 3 years experience working as an acute hospital case manager
Thorough knowledge of principles and practice of health care is required
Excellent writing skills are required
Through knowledge of evidence-based practices is required
Requires excellent organizational and analytical skills with strong abilities for independent decision making and problem solving
Requires excellent communication skills to interdisciplinary team
Bachelor's Degree or Master's Degree in Nursing
Case management certification
Working knowledge of regulations and provider contracts governing coverage of inpatient services (e.g., Medicare, Medi-Cal, Commercial Payers)
About the ministry you will serve:
Providence Little Company of Mary Medical Center Torrance is a 436-bed non-profit hospital that has served the greater South Bay communities of Los Angeles since 1960. We have a reputation for clinical excellence and sophisticated technology while providing care with a personal, healing touch. In addition to the finest general medical, surgical and critical care services, we offer a number of specialty programs including Cardiovascular Services, Women’s and Children’s Health, Oncology, and Emergency Care. We are proud to be named one of the Top 50 U.S. Hospitals for Heart Care by Thomson Reuters, the only community hospital in California to receive this honor. We were one of five hospitals in the United States recognized by American Hospital Association-McKesson for leadership and innovation in quality improvement. We received The Choice Award by AAHCP for Outstanding Customer Service Delivery, and were one of 24 hospitals and health systems in the nation to receive the Premier Award for Quality by the Premier healthcare alliance. As a member of Providence Health & Services, a Catholic-sponsored healthcare ministry, we believe strongly in respecting the dignity of each person, and give special concern to the most vulnerable members of our community.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Req ID: 305586