**Overview** Founded in 1955 Dignity Health – Northridge Hospital Medical Center is a 394-bed acute care nonprofit community hospital located in Northridge California. The hospital offers a full complement of award winning services including the Leavey Cancer Center a cardiovascular center stroke center the Center for Assault Treatment Services a pediatric medical center and the only pediatric trauma center in the San Fernando Valley. As a leading provider of compassionate high-quality and affordable patient-centered care we share a rich legacy with Dignity Health one of the nation’s five largest health care systems. We are part of a 21-state network of nearly 9000 physicians 62000 employees and more than 400 care centers. Visit dignityhealth.org/northridgehospital for more information. Northrdige Hospital Utilization Review RN Utilization Review Responsible for the review of medical records for appropriate admission status and continued hospitalization. Work in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination Staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market. \#LI-DH \#RN \#Utilization Review RN **Responsibilities** + Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. + Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. + Understand how utilization management and management programs integrate. + Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. + Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. + Collaborates with facility RN Care Coordinators to ensure progression of care. + Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. + Communicates the need for proper notifications and education in alignment with status changes. + Engages with Denials RN or Revenue cycle vendor to identify priorities on concurrent denials based on payer timeframes. + Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate. + Establishes and documents a working DRG on each assigned patient at the time of initial review as directed. + Demonstrates behavior that aligns with the Mission and Core Values of the Organization. + Responsible for completing required education within established timeframes. + Knowledge of CMS standards and requirements. + Ability to work as a team player and assist other members of the team where needed. **Qualifications** + Registered Nurse with current California License required. + Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience required. + Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred. + Knowledge of managed care and payer environment preferred. + Must have critical thinking and problem-solving skills. + Bachelor's Degree in Nursing (BSN) or related healthcare field Preferred. + Current BLS ACLS PALS from the American Heart Association Required. + LA City Fire Card required within 90 days of hire. **Pay Range** $53.41 - $76.02 /hour We are an equal opportunity/affirmative action employer.