Utilization Management Nurse Auditor

Patient Business Services

Provide clinical review, audit, analytical, and quality
improvement support for utilization management, medical necessity
determinations, and denial prevention and response efforts across the health
system. As the Utilization Management Nurse Auditor, you will conduct
concurrent and retrospective case reviews, support denial appeals, analyze
utilization and denial trends, and collaborate with Care Coordination, Clinical
Documentation Integrity, Revenue Cycle, and Physician Advisor teams. This role
helps strengthen level-of-care determinations, clinical documentation, payer
compliance, and operational and financial performance.

In this role, you will:

* Review concurrent and retrospective clinical denials to assess admission
status, level of care, length of stay, medical necessity, and other factors
contributing to denials.

* Prepare clinical summaries and supporting documentation for first- and
second-level appeals, support payer, RAC, and Medi-Cal audit responses, and
collaborate with Revenue Cycle and Physician Advisor teams to strengthen appeal
strategies.

* Analyze denial and audit findings to identify trends, root causes,
documentation gaps, avoidable delays, and opportunities to improve utilization
management performance.

* Evaluate cases using established utilization review criteria, including
InterQual, MCG, organizational guidelines, and payer requirements, and escalate
complex or questionable cases as appropriate.

* Partner with Physician Advisors, Care Coordination teams, and clinical staff
to improve documentation supporting medical necessity, status designation, and
accurate level-of-care determinations.

* Prepare reports, dashboards, presentations, case summaries, trend analyses,
and recommendations for leadership and Utilization Management Committee review.

* Support performance improvement initiatives focused on length of stay,
avoidable days, denial rates, status accuracy, utilization outcomes, and data
integrity.

* Serve as a clinical resource while collaborating with clinical and
operational leaders across the health system to support utilization management,
clinical quality, patient safety, care progression, discharge planning, and
continuous improvement efforts.

Required

* Bachelor's degree in Nursing or a related healthcare field, or an equivalent
combination of healthcare education and experience.

* Five or more years of professional healthcare experience in a clinical,
quality improvement, utilization management, or related setting.

* Three or more years of experience in utilization management, case management,
and/or clinical auditing.

* Active, unrestricted Registered Nurse license in California.

* Thorough knowledge of utilization management criteria, including InterQual
and MCG guidelines.

* Thorough knowledge of payer requirements, medical necessity determinations,
and denial management processes.

* Advanced knowledge of quality improvement standards, clinical chart review,
abstraction methodologies, and regulatory requirements.

* Ability to use data collection, aggregation, validation, analysis, and
reporting techniques to support utilization management and quality improvement
activities.

* Strong analytical and critical thinking skills with the ability to interpret
complex clinical, operational, and financial information.

* Strong written and verbal communication skills for preparing reports,
summaries, recommendations, and appeal documentation.

* Ability to collaborate effectively with physicians, clinical staff,
operational leaders, and external regulatory representatives.

* Proficiency with electronic health records and healthcare data management
applications, including familiarity with systems such as Epic.

* Project management and organizational skills with the ability to manage
multiple priorities and deadlines.

Preferred

* Master's degree in Healthcare Administration, Public Health, Business
Administration, or a related field.

* Certification in Case Management (CCM), Certified Professional Utilization
Review (CPUR), Certified Professional Coder (CPC), or a related specialty.

* AAPC certification, such as Certified Professional Coder, Certified
Professional Biller, or Revenue Cycle Management Specialist