Rn Jobs in San Jose, AZ

About The Position

Requirements

• Active and unrestricted Alaska Registered Nurse (RN) license
• Bachelor of Science in Nursing (BSN)
• Minimum 8 years of clinical nursing or patient-care experience
• Minimum 3 years of experience in one or more of the following: Medical record/chart review, Utilization review or utilization management, Risk management, Quality management, Case management, Related healthcare quality services
• Current BLS – American Heart Association
• Current ACLS – American Heart Association
• Strong knowledge of medical terminology, anatomy, physiology, and disease processes
• Strong written and verbal communication skills
• Excellent organizational and prioritization abilities
• Ability to independently evaluate complex clinical information
• Experience with Medical necessity review
• Experience with Level-of-care determination
• Experience with Inpatient chart review
• Experience with Concurrent review
• Experience with Continued-stay review
• Experience with Healthcare reimbursement requirements
• Experience with Public and private insurance processes
• Experience with CMS regulations
• Experience with Clinical documentation review
• Experience with Risk and quality assessment
• Experience with Resource utilization
• Working knowledge of ICD coding principles
• Working knowledge of CPT coding principles
• Working knowledge of Centers for Medicare & Medicaid Services (CMS) requirements
• Working knowledge of Hospital reimbursement processes
• Working knowledge of Medical necessity criteria
• Working knowledge of Clinical documentation standards
• Working knowledge of Healthcare regulatory requirements
• Flu vaccination is required unless an approved exemption is permitted under facility policy.
• All required certifications and licenses must remain current throughout the contract.

Nice To Haves

• Case Management certification from a recognized certifying organization
• CCM – Certified Case Manager
• Other recognized utilization management or case management certification
• Previous inpatient hospital case management experience
• Utilization Review RN experience
• Clinical Documentation Improvement experience
• Risk management experience
• Quality improvement experience
• Medicare and Medicaid reimbursement knowledge
• Previous travel nursing experience

Responsibilities

• Review inpatient medical records for medical necessity and appropriate level of care.
• Evaluate patient status and documentation to support appropriate admission and continued-stay decisions.
• Conduct concurrent and retrospective medical record reviews as required.
• Assess clinical documentation for completeness and alignment with reimbursement requirements.
• Support utilization management and appropriate use of hospital resources.
• Collaborate with physicians and clinical staff to clarify documentation and care requirements.
• Identify potential barriers to appropriate patient progression and coordinate resolution.
• Review patient cases for compliance with payer and regulatory guidelines.
• Support appropriate reimbursement from Medicare, Medicaid, and commercial insurance plans.
• Apply knowledge of CMS requirements to inpatient care and utilization review activities.
• Assist with denial prevention and identify documentation issues that may affect reimbursement.
• Communicate with payers and utilization review representatives when required.
• Participate in interdisciplinary rounds and patient-care discussions.
• Support safe and appropriate transitions between levels of care.
• Identify quality, risk, or patient-safety concerns through medical record review.
• Escalate cases requiring physician, leadership, or multidisciplinary review.
• Maintain accurate and timely documentation of utilization and care-coordination activities.
• Protect confidential patient information and comply with all privacy requirements.
• Collaborate effectively with providers, nursing staff, patients, case managers, and hospital leadership.