Job Description
The Utilization Review Case Manager is responsible for assessing the medical necessity, appropriateness, and efficiency of patient care services. Utilizing evidence-based clinical criteria such as InterQual, MCG, and the CMS Two-Midnight Rule. The UR Case Manager performs initial, concurrent, and retrospective reviews to ensure accurate patient status, appropriate level of care, and optimal length of stay. In this role, the UR Case Manager collaborates closely with physicians, care coordinators, payers, and the interdisciplinary care team to secure timely authorizations, optimize utilization of hospital resources, and support high-quality, patient-centered outcomes. The UR Case Manager proactively identifies barriers to discharge, monitors patient progression, and helps reduce denials through precise documentation and effective communication. The incumbent requires strong clinical judgment, critical thinking, and communication skills, along with the ability to work both independently and collaboratively in a fast-paced, multidisciplinary environment. Serving as a key liaison between the clinical team and payers, the UR Case Manager plays a vital role in ensuring regulatory compliance, appropriate reimbursement, and safe, efficient, patient-centered care.
Qualifications
Education
Experience
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3 years In acute nursing - minimum
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2 years Case Management - preferred
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1 year CPT coding - preferred
Licenses and Certifications
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.
