The Utilization Management (UM) RN performs utilization review activities, including, but not limited to, precertification, ensures appropriate level of care and status (Inpatient, Outpatient, and Observation) throughout admission and performs initial reviews, concurrent reviews, and retrospective reviews according to guidelines. Determines the medical necessity of requests by performing first level reviews. The UM nurse ensures a process that is efficient for providing care, ensuring timely and appropriate levels of care for the incoming patients. UM RN is responsible for preparing cases for Physician Advisor for 2nd level review. UM RN delegates accordingly to LVN and works in conjunction with a multi-disciplinary team to manage the care of patients in an ethical and fiduciary responsible manner.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Excellent verbal and written communication skills

• Ability to follow chain of command

• Highly developed ability to multi-task and maintain focus

• Proactive, can-do approach and desire to build positive working relationships through collaborative
  problem-solving

• Self-motivated and results oriented. Must be able to demonstrate sound decision making, flexibility
  and prioritization skills with minimal supervision.

• Strong organizational skills

• Basic computer skills: Word, Excel, PowerPoint, Outlook. Able to utilize multiple electronic systems.

• Type 50 WPM

• Ability to apply appropriate UM criteria

Required Experience

• Current licensure as an RN in the state of California.
• A minimum of 2 years of bedside nursing experience in an acute care setting.
• A minimum of 2 years of case management experience.
• Knowledge of payer requirements.

****Preferred:

• Certified Case Manager or Accredited Case Manager
• BSN preferred
• Experience with Milliman Care Guidelines (MCG)

• Excellent verbal and written communication skills

• Ability to follow chain of command

• Highly developed ability to multi-task and maintain focus

• Proactive, can-do approach and desire to build positive working relationships through collaborative
  problem-solving

• Self-motivated and results oriented. Must be able to demonstrate sound decision making, flexibility
  and prioritization skills with minimal supervision.

• Strong organizational skills

• Basic computer skills: Word, Excel, PowerPoint, Outlook. Able to utilize multiple electronic systems.

• Type 50 WPM

• Ability to apply appropriate UM criteria