Experience
- Minimum 3 years of acute medical care management or utilization review experience required
- Experience performing utilization review in a hospital setting required
- Proficient with Epic, recent use required within the last 6-12 months
- Experience with Medicare regulations regarding specific utilization management processes required
License & Certification Required
- California RN license required
Skills Required
- Utilization review
- Knowledge of CMS regulations
- Concurrent review
- Pre-certification review
- Prior authorization
- Retrospective review
- Understanding of medical necessity per evidence-based guidelines
- Ability to determine admission criteria
- Familiarity with DRG (Diagnosis Related Groups)
- Knowledge of HIPAA guidelines
- Experience with acute hospital settings
- Knowledge of InterQual criteria
- Experience with CPT coding and billing
Desired Skills
- Experience with HMOs and IPAs
- Knowledge of Medi-Cal
- Experience with pediatric populations preferred
