Lead, IP Utilization Management, Full-time, days

The Utilization Management Lead RN has the responsibility of providing direct oversight and support to the Emergency Prospective Reviewer Case Managers, Utilization Management Case Managers, and Appeal/Denial Case Managers. Among the responsibilities, the lead will provide real time guidance in aiding in determination medical necessity and appropriateness by utilizing evidence based guidelines (MCG), aid in the management of interfacility transfers from both PIH and Non-PIH facilities, provide assistance with the management of Observation patients, promote streamline processes across all three campuses for the management of the patients who present to the Emergency Department, serves as a point of contact for UM Case Managers when discussing patient status, responsible for escalating performance issues to both Clinical Director and Clinical Manager, provide education on best practices pertaining to discharge planning, and assist with data gathering and reporting of department specific metrics.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier, PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women’s health, urgent care and emergency services.

The organization is recognized by Watson Health as one of the nation’s Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work ^TM.For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Excellent verbal, written, and organizational skills required; ability to follow chain of command
• Knowledge of medical terminology and current third-party payor reimbursement methodologies
• Self-motivated and results oriented
• Must be able to demonstrate sound decision making and prioritization skills.
• Utilizes the approved process to resolve biophysical, psychological, educational, and environmental needs of patient/significant others when administering or explaining care.
• Ability to follow chain of command
• Knowledge of hospital operations especially from an ER, ICU, nursing unit, environmental services and financial perspective.
• Knowledge of EMTALA regulations
• Basic computer skills; Outlook, Word, and Excel
• Proficiency with mainframe and personal computers

Required Experience

• Maintain an active California RN license
• BSN Degree
• Minimum of 2 years acute hospital nursing experience
• 5 years previous experience in case management