Utilization Registered Nurse (RN)

Position Overview

Medix is seeking a dedicated Utilization Registered Nurse (RN) to coordinate and implement transition-of-care services for program participants. Under the supervision of the Director of Utilization Management, this role focuses on improving clinical outcomes, supporting appropriate utilization of healthcare services, and coordinating care for acutely and chronically ill participants.

The ideal candidate has strong clinical assessment and care coordination skills, experience working with older adults, and the ability to collaborate with hospitals, healthcare facilities, providers, and interdisciplinary care teams.

Key Responsibilities

• Proactively manage the care of acutely and chronically ill participants to improve quality outcomes and reduce healthcare costs.
• Conduct prospective, initial, concurrent, and retrospective reviews of inpatient, facility, outpatient, and home health services to evaluate medical necessity and appropriateness of care using InterQual or other approved clinical guidelines.
• Collaborate with hospital case managers, facility case managers, hospitalists, and treating providers to improve care coordination and transition processes.
• Assess clinical risks and quality concerns, escalating issues to the interdisciplinary team, providers, Medical Director, and Director of Quality and Compliance as appropriate.
• Partner with the Medical Director and treating physicians to evaluate discharge plans, home care needs, covered services, and alternative levels of care.
• Present participant status updates and address barriers to discharge and care transitions during interdisciplinary team meetings.
• Complete semiannual assessments and annual reassessments to evaluate participants' transition-of-care needs, documenting all assessments and services in the electronic medical record (EMR).
• Visit participants in hospitals, skilled nursing facilities (SNFs), board-and-care facilities, assisted living facilities (ALFs), and private residences as needed.
• Conduct home visits to assess medical status and care needs as recommended by the interdisciplinary care team.
• Coordinate transition-of-care services, including nursing, physical therapy, occupational therapy, speech therapy, and home care.
• Complete and submit Level of Care Assessment Tools (LOCATs) for participants residing in contracted facilities.
• Collaborate with the Director of Quality and Compliance to oversee transition-of-care quality assurance activities.
• Assist with documenting and resolving participant grievances, appeals, rights violations, and other concerns related to services and quality of care.
• Participate in quality improvement initiatives and maintain compliance with organizational policies and participant rights requirements.

Required Qualifications

• Graduate of an accredited school of professional nursing.
• Active Registered Nurse (RN) license through the California Board of Registered Nursing.
• At least two years of RN experience.
• At least one year of experience working with frail or elderly populations.
• Current CPR/BLS and First Aid training, as required.
• Valid California driver's license.
• Ability to complete required TB screening and a health examination.
• Knowledge of medical terminology and regulations related to long-term care.
• Proficiency with computers, data entry, and electronic medical records.
• Strong clinical assessment, organization, communication, and problem-solving skills.
• Ability to make independent clinical decisions when appropriate and work effectively as part of an interdisciplinary team.
• Ability to communicate professionally with participants, families, providers, and healthcare facility staff.

Preferred Qualifications

• Experience in home health, community health, care coordination, or transition-of-care nursing.
• Experience working with older adults or individuals with complex medical needs.
• Familiarity with utilization review and medical necessity criteria, including InterQual.

Additional Requirements

• Ability to conduct visits at healthcare facilities and participants' residences as needed.
• Ability to manage competing priorities and adapt to changing participant needs.
• Commitment to participant dignity, confidentiality, independence, and quality of care.
• Ability to meet the physical requirements of the position, including moving throughout the workday and lifting or carrying up to 25 pounds, with or without reasonable assistance or mechanical devices.

Schedule: Monday - Friday 8-5pm

*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.