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Utilization Review Case Manager

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Requisition # HRC0682830

Are you ready to bring your expert clinical skills to a world-class facility recognized as one of the top ten in the United States? Do you have a passion for the highest quality and patient happiness? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you.

When the work you do every single day has a crucial impact on the lives of others, every effort, every detail, and every second matters. This shared culture of happiness, passion and dedication pulses through Cedars-Sinai, and it’s just one of the many reasons we’ve achieved our fifth consecutive Magnet designation for nursing excellence. From working with a team of dedicated healthcare professionals to using state-of-the-art facilities, you’ll have everything you need to do something incredible—for yourself, and for others. Join us, and discover why U.S. News & World Report has named us one of America’s Best Hospitals.

 

Summary of Essential Duties:

  • Validate patients' placement to be at the most appropriate level of care based on nationally accepted admission criteria

  • Use medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay

  • Secure authorization for clinical services through timely collaboration and communication with payers as required

  • Follow the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review

  • Collaborate with Care Coordinators to identify and follow up on Observation class patients

  • Follow up with the payer to verify approval/authorization of the hospital stay (all dates of services)

  • Function as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to ensure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization

 

Qualifications:

Education:

  • Graduate of an accredited nursing program required

  • BSN preferred

License/Certification:

  • Current, unrestricted California RN license required

  • American Heart Association BLS required

Experience:

  • A minimum of 3 years of acute care nursing experience required

  • 2+ years of case management experience preferred

  • Knowledge of medical literature, research methodology, health care delivery systems and financial reimbursement required

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu). For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through March each year) as a condition of employment, and annually thereafter as a condition of continued employment.

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

Qualifications:

Education:

  • Graduate of an accredited nursing program required
  • BSN preferred

License/Certification:

  • Current, unrestricted California RN license required
  • American Heart Association BLS required

Experience:

  • A minimum of 3 years of acute care nursing experience required
  • 2+ years of case management experience preferred
  • Knowledge of medical literature, research methodology, health care delivery systems and financial reimbursement required
  • Working Title: Utilization Review Case Manager
  • Department: Utilization Management
  • Business Entity: Corporate Services
  • City: Los Angeles
  • Job Category: Patient Services
  • Job Specialty: Case Management
  • Position Type: Full-time
  • Shift Length: 8 hour shift
  • Shift Type: Day

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy.

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