Health System Nurse Case Manager I/II - RUHS Medical Center - Utilization Review/Case Management

The County of Riverside - Riverside University Health System-Medical Center is seeking highly skilled and experienced Registered Nurses to join our team as a Health System Nurse Case Manager with the UR Case Management Department.

The most competitive candidates for this role will have a strong background in hospital case management and utilization review management.

Experience with or a thorough knowledge of InterQual criteria is highly preferred, as it will enhance the candidate's ability to evaluate and coordinate care effectively.

Highly Preferred Qualifications:


* Acute Hospital Case Management and Utilization Review experience is highly preferred.


* Case Manager Certification (CCM)


* Interqual experience/Interqual certification a plus


* Knowledge in electronic health record systems (EPIC)


* Knowledge of healthcare regulations and reimbursement processes.

Work Schedule:


* Hours to be determined by the department.

Meet the Team!
To find out more about Riverside University Health System, please visit:
http://www.ruhealth.org• Within the full scope of the Nursing Practice Act, plan, implement, coordinate, monitor, and evaluate medical services; provide nursing case management, discharge planning and utilization review services to patients; act as department resource for medical inquiries, claim file reviews and utilization review.

• Coordinate and monitor patients through the hospitalization process utilizing physicians, nurses, other healthcare providers, and third-party payors to maintain quality care and fiscal responsibility; monitor completion of healthcare services to avoid delays in care and discharge; facilitate third party reimbursement approval and/or authorization.

• Provide and coordinate community-based medical post-discharge activities for patients provide early medical management intervention for new patient illness/disease, consulting on medical only files and utilization review on all requests for medical treatment; review the post-hospital care plan with the patient/family; follow plan through to discharge.

• Evaluate healthcare services of requesting physicians based on the appropriateness of the service and the level of care at which service would be delivered; act as a neutral advocate for patients; act as a resource to physicians for adequate medical record documentation, appropriateness of facility services as they relate to diagnoses, and options for post-discharge care.

• Perform utilization review in concert with the utilization review physician to approve, delay, modify, or deny treatment.

• Perform medical reviews on patient services claims and provide recommendations, which are preemptive and focused on moving the patient along the healing continuum.

• Apply clinical expertise as a resource to case management staff, physicians, nurses, and other healthcare providers to identify the best results while coordinating the appropriate resource utilization; identify ...