UTILIZATION REVIEW RN

Join our teams as a Utilization Review RN

This role is integral to optimizing patient care and financial integrity by ensuring accurate admission status and continued hospitalization through expert medical record review. The incumbent actively engages in interdisciplinary collaboration with attending physicians, consultants, second-level physician reviewers, and Care Coordination staff, applying evidence-based guidelines and critical thinking to all evaluations. A critical function includes partnering with Concurrent Denial RNs to conduct root cause analysis of denials and implement effective prevention strategies. The position also interfaces with Patient Access to verify appropriate payer sources for patient stays, maintaining comprehensive documentation of these interactions. Furthermore, this role is responsible for securing inpatient authorizations or providing essential clinical guidance to Payer Communications staff to facilitate timely and accurate communication with insurance providers for all required admission and continued stay approvals within the designated market.

• 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.
• 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.
• Ability to work as a team player and assist other members of the team where needed.

Required:

• Graduate of an accredited school of nursing
• 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.

Prefered: 

• 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.
• LA City Fire Card required within 90 days of hire.

Founded in 1955, Dignity Health - Northridge Hospital Medical Center is a 394-bed, acute care, nonprofit hospital located. Serving over 80,000 patients annually, the hospital offers a full complement of services including a Level II Trauma Center, heart care, cancer care and women’s health. It is the only pediatric trauma center in the San Fernando Valley. 

Additionally, Northridge Hospital Medical Center has been recognized as an LGBTQ+ Healthcare Equality High Performer by the Human Rights Campaign Foundation. It is a Joint Commission-certified Thrombectomy-Capable Stroke Center and has been recognized as one of America’s 50 Best Hospitals by Healthgrades in 2026.

One Community. One Mission. One California