UTILIZATION REVIEW NURSE SUPERVISOR I

Los Angeles County (CA) • Los Angeles, CA

63d

About The Position

The Los Angeles County Department of Health Services (DHS) is more than just a healthcare provider - we're a cornerstone of our community's health. As the second largest municipal health system in the nation, DHS operates an integrated network of 25 health centers and four hospitals, alongside an expanded network of community partner clinics. Every year, we deliver compassionate, life-saving care to over 600,000 unique patients across LA County. With more than 23,000 dedicated staff members and an annual budget exceeding $6.9 billion, DHS is dedicated to transforming healthcare and creating lasting change in our community. DHS is seeking dedicated Utilization Review Nurse Supervisors to join our team. Whether you're working in community clinics or hospitals, this is your opportunity to grow your career while serving diverse communities across LA County. Definition: Provides technical and administrative direction to staff performing reviews of patients' medical charts to ascertain the medical necessity for services and the appropriateness of the level of care.

Requirements

• OPTION I: One year of experience performing the duties of a Utilization Review Nurse or Medical Service Coordinator, CCS.
• OPTION II: Two (2) years of experience as a registered nurse, of which one year must be in the treatment of chronic and short- term medical and surgical inpatient problems, AND one (1) year of experience in the first-level supervision of registered nurses and other nursing staff.
• A current, active license to practice as a Registered Nurse issued by the California Board of Registered Nursing.
• A current Basic Life Support (BLS) for Healthcare Providers (CPR & AED) Program certification issued by the American Heart Association.
• For this examination, supervision MUST include all the following: planning, assigning, reviewing work of staff and formally evaluating employee performance.

Nice To Haves

• A Bachelor's Degree in Nursing or higher from an accredited institution.
• Additional experience of first-level supervision of registered nurses and other nursing staff in excess of the selection requirements.

Responsibilities

• Plans, directs, assigns, and evaluates the work of subordinates engaged in utilization review activities.
• Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely utilization review system.
• Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures.
• Determines need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures.
• Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement.
• Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters.
• Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information.
• Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies.
• Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies.
• Attends Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance, as needed.
• Has immediate responsibility for organizing, assigning, and evaluating the work of at least seven Utilization Review Nurses.
• Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards.
• Participates in the formulation of and changes in utilization review procedures by assessing the effectiveness of the review system and providing information on the policies and procedures within the assigned medical areas.
• Provides input for the in-service training program by identifying areas of deficiency in staff knowledge or experience.
• Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for follow up on referrals.
• Reviews, retrospectively, Utilization Review Records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information.
• Compiles data on number and status of reviews, physician advisor referrals, and type of physician advisor determinations.
• Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system.
• Participates in the work performed by subordinates.

Benefits

• We offer one of the strongest public-sector benefits packages in the country. Join us and discover a rich selection of health care options, robust retirement plans and the flexibility to work, relax and rejuvenate as you reach your fullest personal and professional potential.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Administration of Housing Programs, Urban Planning, and Community Development
• Education Level: No Education Listed
• Number of Employees: 101-250 employees