Utilization Review Nurse - Case Management - Full Time

Kern Medical • Bakersfield, CA

39d • $44 - $69

About The Position

Under supervision, the Utilization Review Nurse provides and implements a hospital utilization review and discharge planning program. The position is assigned to Kern Medical Center’s Utilization Review division and performs clinically oriented medical chart reviews and administrative tasks to meet the medical center’s utilization review plan, applicable state and federal regulations, insurer reimbursement requirements, and facility accreditation standards. Responsibilities range from administrative utilization review and discharge-planning work to applying in-depth knowledge of relevant regulations and developing discharge plans through familiarity with outside agencies and services.

The role evaluates inpatient records, conducts ongoing utilization reviews, coordinates with physicians and hospital services, and develops discharge plans. It also addresses payer documentation and authorization requirements, supports appropriate reimbursement, and coordinates with clinics, correctional facilities, admitting staff, and external healthcare providers as needed. The position requires a valid California Registered Nurse license and qualifying acute-care nursing or case-management experience. Required certifications and competencies may apply based on unit needs; employees must maintain RQI Provider certification and competency after completing the required training.

Requirements

• Possess a valid Registered Nurse license in the State of California.
• Meet one of the following experience pathways: 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; or two years of experience as a case manager in an alternate medical setting, such as a clinic or physician’s office, performing utilization review or discharge planning.
• Possess and maintain specific certificates or competencies if required by unit-specific requirements.
• If not holding an American Heart Association Provider Basic Life Support (BLS) card at hire, complete appropriate training and qualify for RQI Provider certification within 60 days of employment; maintain RQI Provider certification and competency as a continued condition of employment.
• Know payer-source documentation requirements and governmental regulations affecting reimbursement; acute-care nursing principles, methods, and commonly used procedures; common disease processes and usual treatments; medical terminology, hospital routine, and commonly used equipment; and acute hospital organization and relationships among clinical and diagnostic services.
• Be able to evaluate hospital admission records for continuing-stay necessity, appropriateness of setting, delivered care, ancillary service use, 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, healthcare providers, external payer sources, and the general public.
• If job responsibilities require driving a personal vehicle, possess a current valid California Driver’s License and comply with the applicable vehicle-use and driving policy.
• If job responsibilities require driving a Kern Medical-owned, leased, or rented vehicle, possess a current valid California Driver’s License, sign an authorization for release of driver-record information, and comply with the applicable vehicle-use and driving policy.
• All Kern County employees are designated Disaster Service Workers and are expected to remain at work or report as soon as practicable after a significant emergency or disaster.

Responsibilities

• Obtain and evaluate inpatient medical records to determine whether required documentation is present.
• Obtain records required by payer 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 payer-source problems and intervene to facilitate appropriate referrals.
• Coordinate with the admitting office to avoid inappropriate admissions.
• Coordinate specialized-test scheduling with clinic areas and other healthcare providers, assess payer 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 payer documentation requirements to maximize hospital reimbursement.
• Initiate and complete Disease Related Groups (DRGs) for Medicare payment.
• Teach providers payer documentation requirements to maximize hospital reimbursement.
• May assist in training other Utilization Review Nurses.
• Keep informed about patient disease processes and treatment modalities.
• Perform other job-related duties as required.

Benefits

• $6,000 new-hire bonus.
• New-hire premium of 6% of base pay, matched up to 6% if 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 employer 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