The Utilization Management (UM) RN performs utilization review activities, including, but not limited to, precertification, ensures appropriate level of care and status (Inpatient, Outpatient, and Observation) throughout admission and performs initial reviews, concurrent reviews, and retrospective reviews according to guidelines. Determines the medical necessity of requests by performing first level reviews. The UM nurse ensures a process that is efficient for providing care, ensuring timely and appropriate levels of care for the incoming patients. UM RN is responsible for preparing cases for Physician Advisor for 2nd level review. UM RN delegates accordingly to LVN and works in conjunction with a multi-disciplinary team to manage the care of patients in an ethical and fiduciary responsible manner.

Qualifications

Skills:

• Excellent verbal and written communication skills
• Ability to follow chain of command
• Highly developed ability to multi-task and maintain focus
• Proactive, can-do approach and desire to build positive working relationships through collaborativeproblem-solving
• Self-motivated and results oriented.
• Must be able to demonstrate sound decision making, flexibilityand prioritization skills with minimal supervision.
• Strong organizational skills
• Basic computer skills: Word, Excel, PowerPoint, Outlook. Able to utilize multiple electronic systems.   
• Type 50 WPMAbility to apply appropriate UM criteria

Experience:

• Current licensure as an RN in the state of California.
• A minimum of 2 years of bedside nursing experience in an acute care setting.
• A minimum of 2 years of case management experience.
• Knowledge of payer requirements.

About the Hospital

PIH Health Hospital - Downey is a nonprofit hospital with a rich, nearly 100-year history of meeting the healthcare needs of its community.

The Downey campus is part of the PIH Health comprehensive health network consisting of two hospitals, 18 medical office locations and a host of specialty services.

According to US News & World Report, the hospital scores highly in patient safety and orthopedics. With 955 employees, the hospital is the 5th largest employer in the city of Downey.