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UTILIZATION REVIEW/CASE MANAGEMENT NURSE OR CLINICIAN - Per Diem (7:00-3:30 pm days vary base on necessity)

San Diego, CA

  Position Summary:

To proactively monitor and optimize reimbursement from external reviewers/third party payers.

 Essential Duties:

  • Conducts admission reviews.
  • Conducts concurrent and extended stay reviews.
  • Prepares and submits appeals to third party payers.
  • Maintains appropriate records of the Utilization Review Department.
  • Provides staff in-service training and education.
  • Assists with training new staff to the department.


Qualifications at Entry:

Graduate of accredited RN or LVN program and current RN or LVN license; LMFT,  Masters degree preferred; excellent telephone usage skills and strong verbal skills; knowledge of health care service delivery systems and third party reimbursement; knowledge of managed care environment; ability to apply and interpret admission and continued stay criteria; understanding of admission and discharge function; familiarity with medical terminology, diagnostic terms and treatment modalities; knowledge of medical record keeping; strong interpersonal, organizational, evaluative, and time management skills; policy interpretation skills; familiarity with applicable standards and regulations; flexibility; attention to detail; able to comprehend psychiatric evaluations, consults, lab results, etc.; responsiveness to deadlines; assertiveness, persistence, and persuasiveness; able to work with minimal direction or supervision.

Current CA RN license, Bachelor of Science in Nursing required/Masters Degree in related field preferred.   Must also be able to cope well with stress, have a strong sense of compassion and communicate well with others.