Utilization Review & Payors Specialist III
Children's Hospital & Research Center Oakland - Oakland, CA

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State License
Licensed Vocational Nurse
Registered Nurse (RN) License
Job Summary:
The Utilization Review New Payor Specialist III provides clinical that includes admission, concurrent and retrospective review to health care payors and review agencies. As part of an interdisciplinary team provides case management services for complex respiratory patients from ICU, this person also supports ICN and MED/Surg case mangers in procuring ordered equipment assuring a safe and timely discharge of patients. The Utilization Review Nurse Payor Specialist III also ensures that patients hospitalized are reviewed for potential Califomia Children's Service (CCS) eligibility, and refers as appropriate.

Position Requirements:
Current California RN License or current LVN license. Experience in all aspects of Utilization Management specific to the function and tasks of Utilization Review, Discharge Planning and Case Management. Concrete knowledge of California Children''s service Medical Eligibility Criteria. CCR Title 22, CCR Title 10, CHCRO's Clinical Practice Guidelines, InterQual Pediatric Medical Management Criteria. Working knowledge of Managed Care and the regulations that govern i.e. MRMIB, CCR Title 22 & Title 10. Computer proficiency Microsoft Office.

Physical Requirements:
Sit: Up to 8 hours/day
Stand/Walk: 3-6 hours
Bend/Stoop: Up to 3 hours
Reach: Up to 3 hours
Rep Use of UE/Grasp: Up to 8 hrs
Lift/Push/Pull: 15 lbs
This job requires the ability to hear alarms clients and/or instruction. The ability to see accurately from 20 inches to 20-ft. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function of this position.

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