Clinical Utilization Review Nurse II (Per Diem, Variable)

NorthBay Health•Fairfield, CA

12d•Onsite

About The Position

At NorthBay Health, the Clinical Utilization Review Nurse II (URN) is an experienced registered nurse who prospectively and concurrently evaluates the appropriateness of inpatient and observation services based on clinical documentation, evidence-based guidelines, and insurance benefits. The URN communicates required clinical information to payers in accordance with contractual and regulatory obligations. The Level II URN serves as a clinical resource to physicians/providers by providing education related to medical necessity, utilization review, and payer requirements.

Requirements

Experienced registered nurse
Demonstrates NorthBay Health’s True North Values: Nurture Care, Own It, Respect Relationships, Build Trust, and Hardwire Excellence.

Responsibilities

Perform comprehensive admission and continued-stay reviews for inpatient and observation cases using facility-approved criteria and payer rules.
Ensure utilization review documentation is accurate, timely, and audit-ready, clearly reflecting clinical facts, criteria application, and rationale.
Identify opportunities for alternative levels of care when criteria are not met.
Identify short-stay risk, disputed status, and medical necessity concerns and escalate to Physician Advisor or leadership as indicated.
Oversee and ensure the Daily Review Tracker, Ambulatory Surgery list, and Observation-to-Inpatient list are consistently maintained, updated, and reviewed in a timely manner; validates data integrity, identifies gaps or delays, and initiates corrective action as needed.
Prepare concise clinical summaries for peer-to-peer discussions and payer communications.
Monitor and report denial trends, avoidable days, and utilization issues within assigned workload for continued process improvement.
Collaborate with revenue cycle on claim issues and appeals.
Analyze population-specific utilization patterns and communicate issues impacting progression of care.
Promote use of evidence-based protocols, pathways, and order sets to support high-quality and cost-effective care.
Participate in audits, quality improvement initiatives, shared governance activities, and ongoing competency development.