This Utilization Review Nurse position requires a Registered Nurse (RN) to perform utilization review functions, ensuring the appropriateness and efficiency of healthcare services. The role involves assessing patient needs, collaborating with the healthcare team, and adhering to regulatory guidelines to optimize resource utilization. Weekend rotation is required every third weekend.
Location: Torrance, California, United States
Responsibilities:
- Assessing patient needs and medical records to determine the appropriateness of care.
- Reviewing patient charts to ensure compliance with utilization management protocols.
- Collaborating with physicians, case managers, and other healthcare professionals.
- Developing and implementing utilization review plans.
- Monitoring patient progress and making recommendations for care adjustments.
- Maintaining accurate documentation of all utilization review activities.
- Adhering to all applicable regulations and guidelines.
- Communicating with insurance companies and other payers regarding coverage.
- Participating in quality improvement initiatives related to utilization management.
Required Skills & Certifications:
- Active Registered Nurse (RN) license in California.
- Bachelor's degree in Nursing or related field.
- Minimum of two years of experience in hospital, home health, or hospice care (this is inferred from the provided options; the provided job description does not specify this requirement for Utilization Review nurses).
- Clinical assessment, medication administration, and treatment planning skills.
- Excellent communication and interpersonal skills.
- Ability to work effectively in a fast-paced environment.
- Proficiency in electronic health record (EHR) systems.
Preferred Skills & Certifications:
- Experience in utilization management or case management.
- Knowledge of medical necessity criteria and payer guidelines.
- Certification in utilization review or case management.
Special Considerations:
- Weekend rotation is required every third weekend.
Scheduling:
- Specific scheduling details are not provided, other than the weekend rotation requirement. Further details should be sought during the interview process.
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