What are the responsibilities and job description for the Utilization Management Nurse Auditor position at UCLA Health System?
Description 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:
status, level of care, length of stay, medical necessity, and other factors
contributing to denials.
second-level appeals, support payer, RAC, and Medi-Cal audit responses, and
collaborate with Revenue Cycle and Physician Advisor teams to strengthen appeal
strategies.
documentation gaps, avoidable delays, and opportunities to improve utilization
management performance.
InterQual, MCG, organizational guidelines, and payer requirements, and escalate
complex or questionable cases as appropriate.
to improve documentation supporting medical necessity, status designation, and
accurate level-of-care determinations.
and recommendations for leadership and Utilization Management Committee review.
avoidable days, denial rates, status accuracy, utilization outcomes, and data
integrity.
operational leaders across the health system to support utilization management,
clinical quality, patient safety, care progression, discharge planning, and
continuous improvement efforts.
Salary Range:
$98,200 to $214,600 annually Qualifications
Required
combination of healthcare education and experience.
quality improvement, utilization management, or related setting.
and/or clinical auditing.
and MCG guidelines.
and denial management processes.
abstraction methodologies, and regulatory requirements.
reporting techniques to support utilization management and quality improvement
activities.
complex clinical, operational, and financial information.
summaries, recommendations, and appeal documentation.
operational leaders, and external regulatory representatives.
applications, including familiarity with systems such as Epic.
multiple priorities and deadlines.
Preferred
Administration, or a related field.
Review (CPUR), Certified Professional Coder (CPC), or a related specialty.
Professional Biller, or Revenue Cycle Management Specialist
$98200-214600 Annually Monday - Friday, 8AM - 5PM
Salary : $98,200 - $214,600