Emergency Prospective Review Nurse, Hybrid, Full-time, FTE 12HR, 830am 9am

PIH Health is a nonprofit regional healthcare network that serves approximately 3 million residents in the Los Angeles County Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital 27 outpatient medical locations a multispecialty medical (physician) group home healthcare services and hospice care as well as heart cancer womens health urgent care and emergency services.

The organization is recognized by Watson Health as one of the nations Top Hospitals and College of Healthcare Information Management Executives (CHIME) as one of the nations top hospital systems for best practices cutting-edge advancements quality of care and healthcare technology. PIH Health is certified as a Great Place to Work ^TM. For more information visit or follow us on Facebook Twitter or Instagram.

The Emergency Prospective Review (EPR) Nurse RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all PIH and non-PIH facilities (for PHP members) after stabilizing care has been initiated for medical necessity and appropriateness. Also the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies Health and Safety Codes and applicable laws (COBRA/EMTALA). The EPR-RN performs and supervises the EPRN-LVN in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient Observation or Outpatient). EPR-RN Communicates medical necessity criteria effectively to outside insurance providers to obtain appropriate authorization for services up front or engages in disagreement of care in accordance with Health and Safety Codes. Additionally EPR-RN collaborates closely with patients insurance and various payors to coordinate and assist with reparation/transfer of out-of-network patients from PIH facility to the patients contracted facility including coordination of post-emergency discharge needs as necessary. EPR-RN is also responsible for the repatriation of all PHP risk patients from non-PIH facilities to any one of the PIH facilities in an expeditious manner. EPR-RN conducts emergency physician-to-emergency physician discussions of members and provides authorization for post-stabilization care of PHP members presenting at a non-PIH facility and is required to assist in making other appropriate arrangements to promote/enhance continuity of care. Similarly EPR -RN is responsible for the issuance of post stabilization care (PSC) denial to facilities and providers who fail to meet requirements in accordance with Health and Safety Codes. Lastly the EPR-RN Works collaboratively with House Supervisor or designee in ensuring timely bed assignment and placement of patient admissions or transfers from PIH ED or outside facility. The position serves as a liaison between patients families providers payors and PIH Health leadership to optimize resource utilization and patient outcomes. This position is considered hybrid with remote and in-office assignment.

• Excellent verbal and written communication skills
• Ability to follow chain of command
• Knowledge of hospital operations especially from an ER ICU nursing unit environmentalservices and financial perspective.
• Knowledge of EMTALA regulations
• Advanced ability to multi-task and maintain focus
• Proactive can-do approach and desire to build positive working relationships through collaborativeproblem-solving
• Self-motivated and results oriented. Must be able to demonstrate sound decision making flexibilityand prioritization skills.
• Strong organizational skills
• Basic computer skills; Outlook Word and Excel