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.