Experience
- Minimum 3 years experience in acute medical care management or utilization review required
- Recent experience with utilization review in a hospital setting required
- Experience with Medicare regulations required
- Proficient with charting systems, specifically Epic, with recent use within the last 6-12 months
License & Certification Required
- Valid California RN license required
Skills Required
- Expertise in concurrent review and continued stay reviews
- Knowledge of admission criteria and care coordination
- Ability to determine medical necessity per evidence-based guidelines
- Experience with CPT coding and billing
- Understanding of DRG (Diagnosis Related Groups)
- Familiarity with HIPAA guidelines
- Clinical skills in ICU, pediatrics, and disease management
- Proficiency in utilization of InterQual criteria
Desired Skills
- Experience with HMOs, IPAs, and other managed care settings
- Knowledge of CA and Medi-Cal processes
- Experience with remote utilization review work
