RN-Case Management (Utilization Review)

Job Title: RN-Case Management (Utilization Review)

Job Location: Bakersfield, CA 93306

Job Duration: 3 Months (Possibilities of Extension)

Shift: 5X8 (40 hrs./Week)

Pay Range: $80/hr. on w2 (Negotiable).

Job Description:

· Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities.

· Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present.

· Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions.

· Conducts on-going reviews and discusses care changes with attending physicians and others.

· Formulates and documents discharge plans.

· Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources.

· Identifies pay source problems and provides intervention for appropriate referrals.

· Coordinates with admitting office to avoid inappropriate admissions.

· Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary.

· Reviews and approves surgery schedule to ensure elective procedures are authorized.

· Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services.

· Answer questions from providers regarding reimbursement, prior authorization, and other documentation requirements.

· Learns the documentation requirements of payor sources to maximize reimbursement to the hospital.

· Keeps informed of patient disease processes and treatment modalities.

· Level II Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital.

· Level II May assist in training Utilization Review Nurse I's. Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient disease processes and the usual methods for treating them; knowledge of medical terminology, hospital routine and commonly used equipment; knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services.

· Ability to effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans; ability to assess and judge the clinical performance of physicians and other health professionals; ability to communicate documentation needs in an effective and tactful manner that promotes cooperation; ability to teach co-workers what is needed and required in the medical record for reimbursement and audit purposes; ability to gather and analyze data and prepare reports and recommendations based thereon; ability to get along with physicians, other health providers, outside payor sources and the general public.

· Performs other job-related duties as assigned.

Education:

· Possession of bachelor’s degree in nursing or successful completion of an accredited Registered Nurse Program as evidence by licensure, from a recognized college or university.

Experience:

· (Level I) Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, at least one (1) of which was on a medical/surgical ward or unit.

· (Level II) One (1) year of utilization review/discharge planning experience in an acute care hospital or as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization review or discharge planning.

· Two (2) 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.

Licenses and Certification:

· Current and valid Unencumbered license as a Registered Nurse issued by the State – Required.

· Current BLS as per American Heart Association standards – Required.

#IRI-RN

Job Type: Contract

Pay: $80.00 per hour

Schedule:

• 8 hour shift
• Day shift

Work Location: In person