RN Utilization Management Lead

About MLK Community Healthcare Be part of our mission to improve the health of our community with compassionate, collaborative, quality care. At MLKCH you will help to positively impact lives, one patient at a time and you’ll complete every shift knowing that your contributions truly matter. Our commitment to the community, and to our employees, make us a great place to work. Benefits: · Loan Forgiveness Eligible Facility · Tuition Reimbursement · No cost medical, dental and vision option · Employee wellness program · Protective equipment · 403 (B) employer match · Generous PTO accrual · Onsite childcare POSITION SUMMARY The RN Utilization Management Lead (RN UM) is an onsite position responsible for overseeing the daily operations of the utilization management team to ensure effective, timely, and compliant review processes for medical necessity, prior authorization, eTARs, denials management, concurrent and retrospective review activities. The Lead collaborates closely with medical directors, care management teams, and other stakeholders to support quality patient care, cost-effective services, and adherence to clinical guidelines and regulatory requirements. The RN Utilization Management Lead (RN UM) coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria. POSITION REQUIREMENTS A. Education • Associates Degree in Nursing or equivalent required. BSN preferred. B. Qualifications/Experience • Minimum 5 years recent experience in Case Management or Utilization Management or Prior Authorization • Current California Registered Nurse License. • Certification in UM or CM is highly preferred • Experience in MCG and/or Interqual required • A team player that can follow a system and protocol to achieve a common goal • Highly organized and well developed oral and written communication skills • Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills C. Special Skills/Knowledge • Bilingual language skills preferred (Spanish) Basic computer skills • Current Basic Life Support (BLS) • CCM Certification preferred Job Type: Full-time Pay: $53.07 - $82.27 per hour Benefits: • Dental insurance • Health insurance • Tuition reimbursement • Vision insurance Experience: • Case Management/Utilization Management/Prior Authorization: 5 years (Required) License/Certification: • CA RN license (Required) Work Location: In person