Utilization Review RN, Care Coordination, Full-Time, Days
About The Position
The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.
Requirements
- Bachelor of Science degree in Nursing preferred
- Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care.
- Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred.
- Experience in applying evidence based criteria related to utilization management.
- Experience using case management software
- Registered Nurse Required at hire
- Basic Life Support Required at hire
- Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
- Able to carry out review function and access medical records.
- Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities.
- Utilization review/discharge planning services appropriate to patients with complex
- Strong attention to detail and accuracy is required.
- Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities.
- Demonstrated ability to work constructively with a broad spectrum of health care professionals is required.
- Must be assertive and creative in problem solving, system planning and management.
- Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products.
Responsibilities
- completion of admission, concurrent and retrospective reviews for designated health plans
- appropriate application of standardized criteria and concurrent documentation
- assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals
- initial RAC review prior to submission to Physician Advisor
- appeal medical necessity denials
- review denials submitted to the case management department from Patient Financial Services to determine if the medical record has sufficient medical necessity documentation prior to a written appeal
- escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
1,001-5,000 employees
