Job Details

The Utilization Management Nurse supports the case management department by by providing a variety of utilization management functions including but not limited to daily screening of patient admission relative to specified criteria, active involvement in denial management, acting as a resource to staff regarding clinical criteria, communication with payors to address concerns and other duties as assigned. The Utilization Management Nurse will work collaboratively with the Utilization Nurse Program Coordinator to ensure compliance with regulatory, organizational and department requirements. The Utilization Review Nurse will receive direction from the Utilization Review Program Coordinator for daily and long term tasks and projects.

The Valley Children’s Hospital Case Management department maintains a collaborative approach in coordinating and optimizing services for our most complex pediatric patients. This includes assessments, care plans, ensuring efficient resource utilization, and fostering communication among the care team. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of the Case Management team include the achievement of optimal health, access to care and appropriate utilization of resources. The case management team is responsible for utilization management, discharge planning and care coordination. This dynamic team aims to enhance the quality of care and support for our patients and families here at Valley Children’s while promoting cost effectiveness and positive outcomes. 

Valley Children’s Healthcare – one of the largest pediatric healthcare networks in the nation – provides Central California’s only high-quality, comprehensive care exclusively for children, from before birth to young adulthood. With more than 670 physicians and 3,500 staff, Valley Children’s delivers high-quality, comprehensive care to more than 1.3 million children in our service area. Our network offers highly specialized medical and surgical services to care for children with conditions ranging from common to the highly complex at our 358-bed stand-alone children’s hospital that includes 28 regional NICU beds. Our family-centered, pediatric services extend from a leading pediatric cancer and blood disorders center home on the West Coast, and a pediatric heart center known for its expertise and pioneering treatments, to a Regional Level IV neonatal intensive care unit (NICU), the highest level referral center between Los Angeles and the Bay Area. We participate in community initiatives, we support community efforts, we get involved where we can do the most good.

EXPERIENCE:

• Minimum 3 years full time or equivalent RN nursing experience in an acute care hospital required
• Pediatric experience, hospital case management/utilization management experience highly desirable
• Knowledge of Utilization Management regulations
• Knowledge of private and public payer reimbursement practices and procedures
• Excellent organizational and communication skills and ability to work with a variety of health care professional
• Ability to work independently
• Proficiency with word processing, spreadsheets and database software

EDUCATION/LICENSES/CERTIFICATIONS:

• Graduate of an accredited nursing program, Bachelor’s in nursing or a field that supports the case management process preferred
• Active California Registered Nurse licensure (RN)

ADDITIONAL SHIFT DETAILS: Weekday coverage 11-1930 and some weekend coverage 0800-1630.

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Disclaimer:  Final compensation will be dependent upon skills and experience.