Case Manager EX - Utilization Management-Days - Remote - Irvine

About the role

Incumbent is responsible for implementing the utilization management process for patients admitted to the hospital. Monitors and coordinates resource utilization throughout the health system and evaluates services provided. Performs the appropriate utilization review functions utilizing medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria). Analyzes and identifies utilization patterns and trends and participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, or routine utilization monitoring activities. Ensures clinical information in the medical record is clear and complete reflecting the patient's true severity of illness through interfacing with physicians to improve the overall quality of the clinical documentation.

Responsibilities

• Monitors and coordinates resource utilization throughout the health system
• Evaluates services provided
• Performs appropriate utilization review functions using medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria)
• Analyzes and identifies utilization patterns and trends
• Participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, or routine utilization monitoring activities
• Ensures clinical information in the medical record is clear and complete reflecting the patient's true severity of illness through interfacing with physicians to improve the overall quality of the clinical documentation

Requirements

Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties Must possess complete understanding of acuity levels for specific patient population Must demonstrate customer service skills appropriate to the job Minimum 5 years of clinical experience and 1 year of previous Case Management experience or a UCI employee who meets the clinical requirements and has a BSN. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job Familiarity of Joint Commission, CMS, CDPH and CCS requirements Excellent written and verbal communication skills in English Current RN License Computer literacy and proficiency All external candidates must have a Bachelor of Science in Nursing Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload Ability to establish and maintain effective working relationships across the Health System

Qualifications

• Complete understanding of acuity levels for specific patient population
• Customer service skills appropriate to the job
• Minimum 5 years of clinical experience and 1 year of previous Case Management experience or a UCI employee who meets the clinical requirements and has a BSN
• Knowledge of standard office equipment and personal computer and computer software skills
• Familiarity of Joint Commission, CMS, CDPH and CCS requirements
• Excellent written and verbal communication skills in English
• Current RN License
• Computer literacy and proficiency

Skills

• Utilization management process implementation
• Resource utilization monitoring
• Medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria)
• Data analysis and trend identification
• Collaboration with physicians for clinical documentation improvement

Benefits

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

Pay

Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php

Conditions of Employment

• Background Check and Live Scan
• Employment Misconduct*
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment
• Misconduct Disclosure Requirement

Closing Statement

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy. We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.