Organization:
SHSO-Sutter Health System Office-Valley

Position Overview:
Conducts prospective, concurrent, and retrospective prior authorization utilization management reviews using clinical criteria and evidence-based guidelines to determine medical necessity, appropriateness of care, and level-of-care requirements for ambulatory, acute, post-acute, and specialty services. Reviews referrals for network adequacy and access to care, identifies appropriate in-network providers and services when available, and facilitates in-network redirection when clinically appropriate and consistent with health plan, regulatory, and organizational requirements.
Coordinates utilization management, resource management, post-acute care referrals, and care facilitation activities to ensure timely, appropriate, cost-effective, and patient-centered care across the continuum. Collaborates with physicians, care teams, health plans, providers, and community resources to support care transitions and optimize utilization of healthcare services.
Prioritizes referral reviews based on regulatory and health plan turnaround time requirements, clinical urgency, and organizational standards, including urgent, injectable, routine, retrospective, and claims-related requests. Maintains compliance with applicable CMS, DMHC, health plan, and organizational policies governing timely access to care, medical necessity determinations, referral classification, documentation requirements, physician involvement as applicable in determinations, and member/provider notifications. Monitors referral aging and ensures timely review and disposition to support compliance, quality outcomes, and audit readiness.
Strives to promote patient wellness, improved clinical outcomes, equitable access to care, and efficient utilization of healthcare resources while supporting regulatory compliance, patient safety, and organizational stewardship for a patient population with complex health needs.

Job Description:

• EDUCATION:
• • Associate Degree in Nursing
  • Other: Graduate of an accredited school of nursing
  
  CERTIFICATION & LICENSURE:
  
  • RN-Registered Nurse of California
  • CCM - Certified Case Manager (certification may be required by entity and time to acquire within 2 years of hire)
  
  TYPICAL EXPERIENCE:
  
  • 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 patients, family, and employee interactions and in performing all job responsibilities.
  • 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 Shift:
Days

Schedule:
Full Time

Shift Hours:
8

Days of the Week:
Monday - Friday

Weekend Requirements:
None

Benefits:
Yes

Unions:
No

Position Status:
Non-Exempt

Weekly Hours:
40

Employee Status:
Regular

Pay Range 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.