Um Nurse - Referral & Auth: Hoag Clinic Utilization Mgmt

Primary Duties and Responsibilities

The Utilization Nurse utilizes clinical expertise, discretion, and independent judgment to utilization management and care coordination methodologies and practices, focusing on the needs of Hoag Hospital and its affiliates (the “Organization”) patient population in partnership with the Organization’s physicians, staff, and inpatient providers.

Inpatient Utilization

Responsible to determine medical necessity of inpatient utilization that includes but not limited to IP admission, continued stay (concurrent), Observation days, based on the recommended Federal, State, Accreditation and National evidence based Inpatient Care Guidelines. The UM Nurse will also be responsible for assisting in the implementation of the discharge plan based upon the physician’s treatment plan/order, patient’s plan benefits, contracted providers/vendors, and medical appropriateness.

Referrals & Authorizations

Responsible for medical necessity review of incoming referrals, Pre-Service, Retro and Post Claims requests. The UM Nurse will review the submitted request and supporting clinical records for Medical Necessity, Clinical Appropriateness, Standards of Care, Experimental and Investigation and the efficient use of health care services consistent with the Federal, State, Health Plan, Accreditation (URAC, NCQA) and national evidence based clinical criteria/guidelines.

Education and Experience

Required:

• At least 3 to 5 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Computer experience in MS Word, Excel and MS Office Programs
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards
• 2 to 3 years of UM review Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.

Preferred:

• Bachelor’s degree in a health care related field

License Required:

• Registered Nurse (RN) in the State of California

License Preferred:

N/A

Certifications Required:

N/A

Certifications Preferred:

N/A

Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year.

For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County’s health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy.

Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes.

Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News &World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California.

To learn more about Hoag’s awards and accreditations, visit: https://www.hoag.org/about-hoag/awards-accreditations/.

Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.