Registered Nurse, Utilization Review

About City of Hope,
City of Hope's mission is to make hope a reality for all touched by cancer and diabetes. Founded in 1913, City of Hope has grown into one of the largest and most advanced cancer research and treatment organizations in the U.S., and one of the leading research centers for diabetes and other life-threatening illnesses. City of Hope research has been the basis for numerous breakthrough cancer medicines, as well as human synthetic insulin and monoclonal antibodies. With an independent, National Cancer Institute-designated comprehensive cancer center that is ranked top 5 in the nation for cancer care by U.S. News & World Report at its core, City of Hope’s uniquely integrated model spans cancer care, research and development, academics and training, and a broad philanthropy program that powers its work. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and cancer treatment centers and outpatient facilities in the Atlanta, Chicago and Phoenix areas.

Provides, coordinates and facilitates patient discharge planning in collaboration with other healthcare professionals during hospitalization. Assists with organizing services across provider lines, between people and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs. Serves as a utilization management resource to determine appropriateness of admission, level of care and continued stay. Maintains a working knowledge of Medicare and private insurance companies and ensures that quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting data to appropriate person(s) and/or department(s).

The successful candidate:

• Collaborates with health care team members to develop a multidisciplinary plan of care and sets patient-centered goals for patient/families.  Facilitates and/or participates in discussions that provide ongoing evaluation of interdisciplinary intervention, goal attainment, and treatment plan revision.
• Knowledgeable about the patient’s financial status, diagnosis and discharge needs to develop the discharge plan of care.  Also maintains an awareness of the patient’s psychosocial situation, including identification of potential barriers which may impact patient compliance and facilitates the coordination of referrals as appropriate.
• Develops collaborative relationships with other departments/entities/external health care agencies to facilitate and support care.
• Initiates discharge planning assessment at the time of admission and collaborates with the multi-disciplinary team for timely discharge. Identifies anticipated discharge date, assesses needs and coordinates services, financial implication of care internally and externally to meet patient needs, including, but not limited to, medications, equipment and home care.
• Assist as needed with obtaining referrals and prior authorization(s) for Home Health Care, hospice, infusion therapy, Durable Medical Equipment (DME), Skilled Nursing Facility (SNF), acute rehab and appointments.
• Provides ongoing communication with patients, families, medical staff, care givers and third-party payers, to include utilization assessment for pre-certification and continued stay justification.  Refers cases that do not meet criteria to the Medical Staff leader.
• Communicate with providers to ensure clinical documentation supports the service and level care provided to the patient.  
• Act as a liaison between CTCA Phoenix and outside agencies (Medicare/Medicaid, commercial, and managed care payers) by providing initial and concurrent clinical reviews (both written and verbal) in order to secure insurance authorization and appropriate reimbursement
• Provides concurrent review of patient admission data within the designated time frames to determine suitability of the level of care in accordance with established criteria.  Works with facility coder to assist with queries requested and concurrent coding needs.
• Must be able to work 3 12's

Qualifications

Your qualifications should include:

• 1-year experience as a Case Manager and /or Utilization Review RN or similar role
• ADN in Nursing
• Arizona Registered Nurse License or a Registered Nurse License form a Compact State
• American Heart Association (AHA) *Basic Life Support (BLS) provider card
• Knowledgeable and able to navigate computer-based applications such as Microsoft products, review software and the electronic medical record

City of Hope is an equal opportunity employer. To learn more about our commitment to diversity, equity, and inclusion, please click here.

To learn more about our comprehensive benefits, click here: Benefits Information

City of Hope employees pay is based on the following criteria:  work experience, qualifications, and work location.