Registered Nurse - Acute Utilization Review Case Manager

Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, andtreatment facilitiesin Atlanta, Chicago and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today.

The Utilization Review Assistant (URA) has the accountability and responsibility to provide duties within the scope of their practice and in a manner consistent with their role and function at City of Hope. Under the supervision of the Case Management Director, the URA is responsible to monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Assists in monitoring the appropriateness of hospital admissions and extended hospital stays. Responsible for the facilitation of communicating with providers, monitors patient charts and records to evaluate care concurrent with the patient’s treatment, reviews status of approval for insurers, supports authorization attainment, facilitates timely information transfer for DME approvals, and maintains patient information through chart documentation in EMR, and provides other support as requested.

The successful candidate:

• Assists in the timely delivery of patient information that is consistent with practice standards including the ethical framework articulated state, and regulatory requirements as well s the mission and values of City of Hope.
• Collaborates with third party payers, case managers, and providers in the facilitation of insurance authorization and documentation.
• Reviews medical records for medical necessity documentation for the purpose of pre-certification or prior authorization. Collaborates with case management team regarding orders to promote continuity of care.
• Obtains prior authorization and retro-authorizations as appropriate
• Monitors the appropriateness of hospital admissions and extended hospital stays, escalates any discrepancies as appropriate
• Coordinates the administrative aspects of the utilization review process involving authorizations, requests for clinical reviews, concurrent denial documents, messages received from payors and identify issues needing further resolution. Determine appropriate UR RN reviewer and refer for handling if necessary.
• Supports patient discharge plans prepared and delegated by social work or nurse case management by coordinating with home care agencies, post-acute care facilities, durable medical equipment companies, transportation agencies and others as indicated.
• Issues CMS Important Messages to patients/designees.
• Provides care in a manner consistent with specific role and function according to COH policy and procedure.
• Prepares documents and reports required for internal and/or external groups in the scope of care coordination activities and/or data collection.
• Assists in collecting data related to patient outcomes and auditing data for accuracy.
• Uses and maintains working knowledge of insurance terms, guidelines and has familiarity with the payer processes for initiating authorizations.
• Demonstrates organizational skills by multitasking, maintaining current work list, and the timely hand off to the RN Utilization Management team in an effort to minimize denials
• Communicates effectively with all Partners, such as RN case managers, physicians, insurance carriers, designate intermediaries, and/or vendors/agencies to ensure that patient information is current, accurate, and complete.
• Monitors main fax line and inputs authorized/approved bed days into patient’s chart and forwards denial notices to the RN Utilization Management team.
• Coordinate all care activities within scope of practice and as directed by Manager and associate unit staff
• Contributes to the achievement of the Utilization Management goals through effective participation in committees and informal work groups. Provides timely and continual coverage of assigned work area to ensure all accounts are completed.
• Maintains up-to-date concurrent authorizations for in-house patients as assigned.
• Assists in maintaining Epic work queues to ensure inpatient bed days, authorization numbers, and additional data is accurate
• Demonstrates competency in organizational software systems.
• Maintains current knowledge and awareness of organizational and regulatory standards, policies and procedures.
• Maintains current knowledge and skills through attendance and participation in organizational and departmental meetings and continuing education activities.
• Demonstrates fiscal responsibility by appropriate and timely use of organizational resources.
• Actively participates in performance improvement activities through data collection and/or participation in corrective action plans to continuously improve service delivery.
• Follows established City of Hope and department policies, procedures, objectives, performance improvement, attendance, safety, environmental, and infection control guidelines, includingadherence to theworkplaceCode of Conduct and Compliance Plan. Practices a high level of integrity and honesty in maintaining confidentiality.
• Must be able to work 4 10's, 8:00am-6:30pm with rotating weekends.

Qualifications

Your qualifications should include:

• 1-year experience as a Case Manager and /or Utilization Review RN or similar role
• Associate Degree in Nursing or equivalent
• Arizona Registered Nurse License or a Registered Nurse License form a Compact State
• Basic Life Support (BLS) Certification- an approved American Heart Association (AHA) training site, American Safety & Health Institute, or Red Cross BLS certification is required upon hire. If their current certification does not meet the guidelines, stakeholders will have (30) days from the date of hire to acquire attend an onsite initial BLS course and will be required to renew every two years.
• Knowledgeable and able to navigate computer-based applications such as Microsoft products, review software and the electronic medical record

City of Hope is an equal opportunity employer. To learn more about our commitment to diversity, equity, and inclusion, please click here.

To learn more about our comprehensive benefits, click here:Benefits Information