Experience
- Minimum 3 years of experience in acute medical Care Management or Utilization Management required
- Experience performing utilization review in a hospital setting required
- Recent experience with Epic required within the last 6-12 months
- Experience with Medicare regulations and specific UM processes required
- Experience with HMOs, IPAs, etc. preferred
License & Certification Required
- California RN License required
Skills Required
- Proficient in Epic charting system
- Knowledge of CMS: Centers for Medicare and Medicaid Services
- Understanding of medical necessity per Evidence-Based Guidelines
- Familiarity with CPT coding and billing
- Knowledge of DRG (Diagnosis Related Groups)
- Maintaining HIPAA guidelines
- Experience with Care coordination
- Experience in Concurrent Review and Continued Stay Reviews
- Experience with Pre-Cert and Prior Authorizations
- Experience with Retrospective Review
- Understanding of The Joint Commission/Core Measure/National Safety Goals
- Experience with remote Utilization Review work
- Experience with CA and Medi-Cal
Desired Skills
- Experience with pediatric patient populations preferred
- Flexibility to support multiple facilities preferred
- Ability to work in Pacific Standard Time required
