Scripps Health UTILIZATION REVIEW CASE MGR (Appeals and Denials)- Full-Time - Day in San Diego, California

Responsible for conducting admission, concurrent, and retrospective case review for all payor sources. Reviews all admissions for appropriate level of care consulting with the physicians regarding appropriate level of care orders. Performs concurrent review to support continued medical necessity and confers with physician on changes in level of care including compliance with CMS regulations. Coordinates communications between attending physician and insurance Medical Director. Supports the development, utilization, implantation, and monitoring of utilization review/performance improvement projects.

Experience/Specialized Skills: 3 to 5 years Clinical experience. Bachelor of Science in Nursing (BSN) preferred. Previous experience in utilization management and discharge planning preferred.

Required Certification/Registration: Current California RN License

Required Education/Course(s)/Training: Completion of certification in Utilization Management within 1 year of hire. Knowledge of Milliman and/or Mckesson InterQual Guidelines.

/ Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability. /

Job: *RN - Clinical

Organization: *Scripps La Jolla Hospital

Title: UTILIZATION REVIEW CASE MGR (Appeals and Denials)- Full-Time - Day


Requisition ID: 1025370