RN II-Case Management/ Utilization Review, Day Shift, Per Diem (CNA)

Adventist Health

3d•Onsite

About The Position

Adventist Health Sierra Vista is a 162-bed acute care facility on California’s Central Coast, with a Level III Neonatal Intensive Care Unit and a county-designated trauma center. The RN II in Case Management/Utilization Review assesses admission status and level of care using InterQual criteria, provides discharge planning, and coordinates with patients, families, community agencies, and medical staff to support appropriate use of hospital resources and high-quality patient care. The role works ten-hour day shifts, with an occasional weekend in rotation, and is represented by CNA. The position reviews assigned patients’ care and progress, completes InterQual reviews, supports admission and payer-guideline decisions, identifies case-management needs, and documents interventions and progress. It also coordinates utilization management, discharge planning, patient transfers, and communication among payers, clinicians, patients, families, and financial counselors. Accurate documentation in patient records and the hospital computer system is required. Other job-related duties may be assigned. Adventist Health requires associates to receive required vaccinations as a condition of employment and annually thereafter where applicable; medical and religious exemptions may apply. The organization participates in E-Verify.

Requirements

Associate degree or equivalent.
Three to five years of nursing experience in an acute care hospital setting.
Current RN license in the state of practice.
Registered Nurse (RN) license in the state of practice.
Basic Life Support (BLS) certification from an approved vendor, per Adventist Health policy.
Basic computer skills, including Word, Excel, Outlook, and Internet navigation.

Nice To Haves

Bachelor’s degree in Nursing.
Recent experience in utilization review, discharge planning, and/or inpatient case management.
Knowledge of InterQual criteria and Medicare Conditions of Participation.

Responsibilities

Assist physicians in deciding whether admission should be observation or inpatient status, considering payer guidelines.
Review patient charts on the day of admission or the first day after admission for SI/IS.
Complete Advance Directive forms as needed.
Identify follow-up case-management needs and document opportunities for intervention based on chart reviews, multidisciplinary referrals, or physician orders.
Coordinate team or family conferences to ensure timely responses to patient needs.
Assist proactively with developing patient-care and teaching plans.
Complete InterQual reviews and review care and progress for assigned patients as often as necessary, but at least every 72 hours, documenting progress in the computer system and patient chart.
Move patients through the system according to their level of need and respond to issues that interfere with the plan of care.
Issue HABN letters as needed and refer cases that do not meet InterQual criteria to the UR advisor.
Obtain optimal patient coverage by furnishing appropriate medical information to insurance carriers and governmental agencies.
Serve as liaison among payers, physicians, patients, families, and the financial counselor.
Collaborate with appropriate team members to maximize reimbursement through essential documentation.
Document authorizations and denials in the computer system when received.
Discuss appropriate inpatient testing proactively with physicians.
Anticipate discharge needs and suggest referrals that connect patients and families with resources inside and outside the healthcare system and community.
Ensure patients are medically stable for discharge and that patients and families are prepared educationally, emotionally, and functionally.
Coordinate timely patient transfers to other facilities.
Accurately document case-management needs, goals, and planned interventions in patient records and the hospital computer system.
Perform other job-related duties as assigned.