Registered Nurse – Utilization Management

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $67 - $75 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Cedars-Sinai

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

💊 Pharmaceuticals

Healthcare • Pharmaceuticals

Cedars-Sinai is a leading healthcare organization that has been addressing the medical needs of a diverse community since its inception in 1902. Renowned for its excellence in patient care, clinical research, and medical education, Cedars-Sinai is recognized nationally for its innovative approaches in healthcare. It is especially noted for its advancements in the treatment of heart disease, cancer, and brain disorders, as well as its comprehensive education programs for healthcare professionals. The institution demonstrates a strong commitment to community service by enhancing the health of vulnerable populations in Los Angeles.

📋 Description

• Assess and determine appropriate levels of care using InterQual, MCG, and the CMS Two-Midnight Rule • Conduct initial and concurrent reviews for inpatient, observation, and outpatient/procedural services • Escalate cases to the UM Medical Director, UM Physician Advisor, or external physician reviewer as needed • Partner with physicians, care coordinators, and interdisciplinary teams on patient classification, care progression, and transitions of care • Verify physician orders and compliance with Medicare, Medicaid, and payer guidelines • Secure reimbursement resources for uninsured and underinsured patients • Communicate clinical information to third-party payers • Track and secure payer authorizations and prevent coverage lapses • Review and overturn concurrent denials; assist with appeals and peer-to-peer discussions • Monitor length of stay, care progression, resource use, and barriers to discharge • Maintain confidentiality, regulatory compliance, and accurate documentation

🎯 Requirements

• Associate degree/college diploma from an accredited nursing program — minimum • 3 years of acute nursing experience — minimum • RN state license — minimum • Basic Life Support (BLS) certification — minimum • Bachelor's degree in Nursing — preferred • 2 years of case management experience — preferred • 1 year of CPT coding experience — preferred • Clinical judgment, critical thinking, and communication skills • Ability to work independently and collaboratively in a fast-paced, multidisciplinary environment • Knowledge of InterQual, MCG, and CMS Two-Midnight Rule guidelines • Knowledge of Medicare, Medicaid, and other payer guidelines