Utilization Review Nurse - Case Management - Full Time

Kern Medical • Bakersfield, CA

6d

About The Position

Kern Medical is an acute care teaching center with 222 beds and a range of primary, specialty, and multi-specialty services. The Utilization Review Nurse works in the Utilization Review division and, under supervision, provides and implements a hospital utilization review and discharge planning program. The role includes clinically oriented medical chart reviews and administrative work to meet the medical center’s utilization review plan, applicable state and federal regulations, payor requirements, and facility accreditation standards.

The position reviews inpatient admissions and ongoing care, coordinates with physicians and hospital services, evaluates documentation and reimbursement requirements, and formulates discharge plans. Depending on experience, the nurse may also apply knowledge of applicable regulations and outside agencies and services to develop appropriate discharge plans. The position may assist in training other Utilization Review Nurses.

Requirements

• Possess a valid Registered Nurse license in the State of California.
• Have two years of experience, or equivalent, as a registered nurse in an acute care hospital, including at least one year on a medical/surgical ward or unit; alternatively, have a California Registered Nurse license and two years of experience as a Case Manager in an alternate medical setting, such as a clinic or physician’s office, performing utilization or discharge planning.
• Possess and maintain specific certificates or competency based on unit-specific requirements when required as a condition of employment.
• If not holding an American Heart Association Provider Basic Life Support (BLS) card at hire, successfully complete appropriate training and qualify for RQI Provider certification within 60 days of employment; maintain RQI Provider certification and competency thereafter.
• Know payor documentation requirements and governmental regulations affecting reimbursement.
• Know acute care nursing principles, methods, and commonly used procedures; common patient disease processes and usual treatments; medical terminology; hospital routines and commonly used equipment; and acute hospital organization and the interrelationships of clinical and diagnostic services.
• Be able to evaluate hospital admission records for continuing-stay necessity, appropriateness of setting, care delivered, use of ancillary services, and discharge plans.
• Be able to assess and judge the clinical performance of physicians and other health professionals.
• Be able to communicate documentation needs effectively and tactfully to promote cooperation.
• Be able to gather and analyze data and prepare reports and recommendations.
• Be able to work effectively with physicians, other health providers, outside payor sources, and the general public.
• A background check may be conducted.
• If job responsibilities require driving, possess a current valid California Driver’s License and comply with applicable vehicle-use and driving policy requirements.

Responsibilities

• Obtain and evaluate medical records for inpatient admissions to determine whether required documentation is present.
• Obtain records required by payor agencies and initiate Physician Advisories when admissions are unwarranted.
• Conduct ongoing reviews and discuss changes in care with attending physicians and others.
• Formulate and document discharge plans.
• Consult and coordinate with hospital services to support efficient use of hospital resources.
• Identify pay-source problems and intervene to facilitate appropriate referrals.
• Coordinate with the admitting office to help avoid inappropriate admissions.
• Coordinate with clinic areas and other healthcare providers to schedule specialized tests, assess pay sources, and authorize payment under the Medically Indigent Adult program when necessary.
• Review and approve surgery schedules to ensure elective procedures are authorized.
• Coordinate with correctional facilities regarding appropriate use of elective procedures, durable medical goods, and other services.
• Answer provider questions about reimbursement, prior authorization, and documentation requirements.
• Learn and teach providers the documentation requirements of payor sources to maximize hospital reimbursement.
• Initiate and complete Disease Related Groups (DRGs) for Medicare payment.
• Keep informed about patient disease processes and treatment modalities.
• May assist with training other Utilization Review Nurses.
• Perform other job-related duties as required.

Benefits

• $6,000 new-hire bonus.
• 6% new-hire premium on base pay, matched up to 6% when contributed to the Deferred Compensation Plan.
• Comprehensive benefits package including holidays, paid time off, retirement, medical, dental, vision, and life insurance.
• May be eligible for participation and company contributions in the Kern County Employees’ Retirement Plan.
• Additional compensation may be available through differentials, incentives, and bonuses.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed