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Pediatric Utilization Review RN

Santa Barbara, CA · Healthcare
Pediatric Utilization Review RN - Managed Care
Santa Barbara, CA
Utilization Review RN Job Summary:
  • The Pediatric Utilization Review Nurse is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review.
  • The UR Nurse will performs reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
  • They will conduct prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests.
  • The focus of this position is Pediatric members, including newborns, infants, children, and adolescents.  As needed, duties may also include expecting mothers (prenatal, perinatal, and postnatal)

Utilization Review RN Background
  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • CCM or CPUR/CPUM/CPHM or similar certification is preferred
  • Roughly 1-2 years acute care clinical nursing experience is required.
  • Around 1-2 years of recent experience in Pediatric Utilization Review or Care Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.

480.646.3201 (CALL – TEXT – FAX)
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