RN Utilization Review

CommonSpirit Health • Santa Cruz, CA

15h • Onsite

About The Position

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Requirements

• Graduate of an accredited school of nursing upon hire
• Minimum two (2) years of acute hospital clinical experience
• Bachelor's Degree in Nursing (BSN) or related healthcare field.
• Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• Registered Nurse: CA (RN:CA Preferred: years of nursing experience.
• Accredited Case Manager (ACM)
• Certified Case Manager (CCM)

Responsibilities

• Review of medical records for appropriate admission status and continued hospitalization.
• Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking.
• Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies.
• Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions.
• Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

What This Job Offers

• Career Level: Mid Level