We are so glad you are interested in joining Sutter Health! Organization: SHSO-Sutter Health System Office-Valley Position Overview: Conducts concurrent utilization management reviews for hospitalized and acute care patients using established clinical criteria and evidence-based guidelines to evaluate medical necessity, appropriateness of care, continued stay, and level-of-care requirements. Assesses the patient’s clinical status and progression of care throughout the hospitalization to support timely, appropriate, and effective utilization of healthcare services.
Collaborates with physicians, hospital care teams, case management, health plans, post-acute providers, and other stakeholders to identify barriers to progression of care, support timely transitions, and facilitate appropriate discharge planning and post-acute services. Escalates cases requiring additional clinical review or physician involvement in accordance with regulatory, health plan, and organizational requirements.
Prioritizes concurrent reviews based on clinical urgency, required review intervals, regulatory and health plan turnaround times, and organizational standards. Monitors continued-stay reviews, length of stay, level of care, documentation needs, and discharge readiness to promote timely clinical decision-making and reduce avoidable delays in care. Maintains accurate and timely documentation to support medical necessity determinations, communication with providers and health plans, regulatory compliance, and audit readiness.
Ensures adherence to applicable CMS, DMHC, health plan, and organizational requirements related to utilization management, physician review, notifications, and coordination of care. Promotes patient-centered care, quality outcomes, safe transitions, and responsible utilization of healthcare resources while supporting regulatory compliance, patient safety, and organizational stewardship for patients with complex acute and post-acute care needs.
Other: Graduate of an accredited school of nursing CERTIFICATION &
RN-Registered Nurse of California TYPICAL
2 years of experience in acute care case management or health plan case management/utilization management required. SKILLS AND KNOWLEDGE: A broad knowledge base of health care delivery and case management within a managed care environment. Comprehensive knowledge of Utilization Review, levels of care, and observation status.
Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: Centers for Medicare and Medicaid Services (GR) Grouper (CMS), Department of Managed Health Care, National Committee for Quality Assurance (NCQA). A broad knowledge base of outpatient, acute, and post-acute levels of care and associated regulatory compliance requirements.
Must be able to effectively communicate with and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners. Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families. Demonstrates commitment to service excellence in all patient, family, and employee interactions and in performing all
. Functions in a manner to promote quality patient care and assure a positive patient experience. Verbal and written communication skills.
Interpersonal communication and negotiation skills. Must have time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities. Intermediate computer skills.
Ability to promote teamwork and to effectively function in teams. Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience. Job
Days
Full Time Shift Hours: 8 Days of the Week: Monday - Friday Weekend
Occasionally
Yes Unions: No Position Status: Non-Exempt Weekly Hours: 40 Employee Status: Regular Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
is $82.48 to $115.46 / hour The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program.
Eligible positions also include a comprehensive benefits package.