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Department:  Nursing
Status:  Full Time
Shift:  1st

The Utilization Management (UM) Nurse – Inpatient Review is responsible to determine medical necessity of inpatient utilization that includes but not limited to IP admission, continued stay (concurrent), Observation days, based on the recommended Federal, State, Accreditation and National evidence based Inpatient Care Guidelines. The UM Nurse will also be responsible for assisting in the implementation of the discharge plan based upon the physician’s treatment plan/order, patient’s plan benefits, contracted providers/vendors, and medical appropriateness.  Responsible for daily interaction with the Medical Director, attending specialist and hospitalist as needed for determination of continued stay and discharge needs. Responsible to collaborate with the Outpatient Case Management (CM) team for any transitions of care needs and physician follow up.



Essential Functions:

  • Conduct telephonic or onsite admissions and concurrent review for all delegated HMO members as assigned in a timely manner based upon the Federal, State, Health Plan, Certification, and Department standards. 
  • Communicate with hospital/facility staff, hospitalist, specialty providers and/or attending providers to gather clinical information needed for admission and continued stay. Notify all parties in a timely manner regarding all determinations.
  • Discuss with the Inpatient Medical Director(s) as appropriate the patient’s treatment plan of care to ensure that the best care is delivered in the most appropriate setting.  Applies medical knowledge to authorize alternative care settings (OP, LTACH, SNF or HHC) as appropriate if Inpatient is not the best care setting for the patient. Assists in arranging for transfer to an in-network facility when appropriate.
  • Consistently and accurately, document any updates in the patient’s clinical condition, treatment plan, discharge plan and concurrent review determination in the Medical Management System. 
  • Ensure access to the Hospital EMR for Clinical Review Updates and clarifies information with the treating doctor as appropriate.
  • Anticipate the appropriate discharge disposition upon admission and prepare any discharge needs to the most appropriate alternative care setting. Identify and authorize post-acute care needs and services to facilitate timely discharge or transfer.
  • Applies appropriate member benefits to plan of care when authorizing any services.
  • Utilizes any Federal, State, Health Plan, Certification and/or national evidence based clinical guidelines and prior medical knowledge in the review process.
  • Collaborate and discuss with the Medical Director on reviews that are not meeting criteria. Provide the pertinent supporting clinical information for their review and determination on both admission and continued stay reviews.
  • Participates in daily or weekly interdisciplinary team (IDT) rounds as appropriate.
  • As needed, may assist in after-hours review and discharge planning activities. This include but not limited to gathering clinical information to determine medical appropriateness for an admission, assist in transfer to an in or out of network facility, and/or set up services needed post discharge.
  • Responsible for assisting the Medical Director in creating the appropriate letter with the correct 6th grade level rationale and template in a timely manner. Notifies the member, the facility and the provider on the determination of each review.
  • Identify and coordinate patient’s need post discharge with the SNF, LTACH, IP rehab, Hospice, Homebound programs, Chronic care, Home Health, PCP or Specialty visit, Out Patient Case Management Team and other services as appropriate.
  • Identify and report under and over utilization of medical services, delays in service by provider or facility or potential quality of care issues to the Medical Director and/or the CM Manager.
  • Protects patient privacy by ensuring all information is shared confidentially and within the HIPPA guidelines on both Medical and Behavioral Health interactions.
  • Actively participates in internal projects and other duties as assigned.


Education, Training and Experience



  • Registered Nurse (RN) in the State of California
  • At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or  Risk Based MSO setting.
  • Computer experience in MS Word, Excel and MS Office Programs
  • Experience with Medicare/Medicare Advantage Plans, Commercial Plans,  HMO, and/or Medi-Cal/ACA standards




  • Bachelors degree in a health care related field
  • 2 to 3 years of Admission and Concurrent review Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.


Skills or Other Qualifications



  • Proficient with computer skills and/or UM applications.
  • Demonstrates strong problem solving skills.
  • Communicates clinical information clearly with the Medical Director and physicians.
  • Effectively articulates clinical and non-clinical information to persons of all levels.  Communicates positively and effectively.


License and Certifications


Required: RN

Preferred: N/A

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