"Case Manager-Utilization Management (Inpatient, ED)-FT-Variable"

Incumbent is responsible for implementing the utilization management process for patients admitted to the hospital. Monitors and coordinates resource utilization throughout the health system and evaluates services provided. Performs the appropriate utilization review functions utilizing medical staff-approved decision support criteria (InterQual Intensity of Service, Severity of Illness criteria). Analyzes and identifies utilization patterns and trends and participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, or routine utilization monitoring activities. Ensures clinical information in the medical record is clear and complete reflecting the patient's true severity of illness through interfacing with physicians to improve the overall quality of the clinical documentation.

Required Qualifications: Must possess the skill, knowledge, and ability essential to the successful performance of assigned duties. Must possess complete understanding of acuity levels for specific patient population. Must demonstrate customer service skills appropriate to the job. Minimum 5 years of clinical experience and 1 year of previous Case Management experience or a UCI employee who meets the clinical requirements and has a BSN. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job. Familiarity of Joint Commission, CMS, CDPH and CCS requirements. Excellent written and verbal communication skills in English. Current RN License. Computer literacy and proficiency. All external candidates must have a Bachelor of Science in Nursing. Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload. Ability to establish and maintain effective working relationships across the Health System.

Preferred Qualifications: Knowledge of University policies and procedures. Knowledge of California Children's Services benefits authorization process (CCS). CCM, ACM. Bilingual skills.