Utilization Review Registered Nurse
Whittier, California
PIH Health Hospital - Whittier

Job Opportunity: Utilization Review Registered Nurse (RN)

Location: Whittier, California
Employment Type: Travel/Contract
Contract Length: 13 weeks

Job Description

• Open to first-time travelers; 2 years of RN experience required for Utilization Review specialty.
• Every other weekend shift required or more depending on unit needs.
• No call or floating required.
• Must have experience with Milliman Care Guidelines and Acute Hospital Experience.
• Role involves reviewing all patients requiring hospital admission from the emergency room for medical necessity and appropriateness after stabilizing care.
• Responsible for reviewing interfacility transfer requests in accordance with transfer policies and applicable laws.
• Supervises Licensed Vocational Nurses (LVNs) in utilization review.
• Uses approved criteria to determine medical necessity for authorization and reimbursement for appropriate levels of care (Inpatient, Observation, Outpatient).

Required Qualifications

• Valid RN license in California
• Utilization Review experience with a minimum of 2 years, including experience within the last year
• Associate of Science in Nursing / Associate Degree in Nursing
• ACLS issued by American Heart Association
• BLS issued by American Heart Association
• Harassment Prevention Training Certificate
• Experience in an Acute Care setting
• Experience with Milliman Care Guidelines
• Concurrent Review experience
• Ability to determine medical necessity per evidence-based guidelines
• Experience with Pre-Cert Review and Prior Authorizations
• Proficient in utilizing Milliman Guidelines
• Knowledge of CMS (Centers for Medicare and Medicaid Services), CPT (Current Procedural Terminology) coding and billing, and DRG (Diagnosis Related Groups)

Skills and Knowledge Areas

• Acute Hospital and Emergency Department care
• ICU experience
• Admission Criteria and Benefits Eligibility
• Care Coordination and Concurrent Review
• Data Abstraction and Medical Necessity Determination per Evidence-Based Guidelines
• Discharge Planning and Needs Assessment
• Pre-Cert Review and Prior Authorizations
• Utilization of Milliman Guidelines
• Knowledge of CMS, CPT coding and billing, DRG, HIPAA, ICD-10 coding, OSHA, and The Joint Commission standards
• Experience with Hard Stop hospital protocols
• Proficiency in Excel

Certifications (as applicable)

• BLS (Basic Life Support) – Required for all clinical starts
• ACLS (Advanced Cardiac Life Support) – Required for ER, ICU, and related units
• Other certifications may be required depending on unit assignment (e.g., PALS, NRP, EFM)

Compliance and Documentation Requirements

• Government-issued photo ID
• Background checks including 7-year criminal history and federal/state databases
• Education verification
• Drug testing (7-panel) within 30 days of start
• Physical exam within 1 year, confirming fitness for duty and communicable disease clearance
• Immunizations or documented immunity for:

  • Tetanus/Diphtheria/Tdap (within 10 years or declination)
  • Measles, Mumps, Rubella (positive titer or vaccination series)
  • Hepatitis B (3-dose series, positive titer, or declination)
  • Varicella (positive titer or vaccination series)
• Negative TB test or chest X-ray within 1 year
• Annual TB questionnaire
• Seasonal flu vaccination or declination during flu season
• COVID-19 vaccination or facility-specific declination during flu season
• Mask fit testing as required by unit (annual renewal)
• Harassment prevention training (California-specific)

Competency and Testing Requirements

• Medication/Pharmacology competency exam (passing score 80%)
• Dysrhythmia/EKG competency exam for relevant units (Medical Surgical, Telemetry, ER, ICU) with two attempts allowed
• Pass/fail testing for EKG/Dysrhythmia onsite during orientation for certain units
• Fetal monitoring competency exam for Labor & Delivery RNs (updated annually)

Additional Information

• Business casual attire preferred.
• Return to Office (RTO) documentation must be submitted upfront.
• Clinical candidates must provide two professional references from managers or charge nurses within the last 2 years.
• Employment application/resume required, documenting at least 1 year of relevant experience and 7 years of work history if applicable.
• Skills checklist updated annually is required for licensed workers.

Prior Travel Experience

• Not explicitly required; first-time travelers are eligible.

This position is ideal for RNs with acute care and utilization review experience seeking a travel contract role in California.