Travel RN Case Manager; Utilization Review

Responsibilities

• 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.
• Answers 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.

• Possession of a valid license as a Registered Nurse in the State of California.
• 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.
• Alternatively, possession of a valid license as a Registered Nurse in the State of California and five (5) 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.
• Incumbents may be required to possess and maintain specific certificates competency based on unit specific requirements as a condition of employment.
• Case management experience in California (excluding Kaiser), preferably more than 1 assignment.
• Able to do both Utilization review and Care Coordination/Discharge planning.