Utilization Review Nurse, RN - Case Management - at Kern Medical Bakersfield, CA

Utilization Review Nurse – Case Management

Kern Medical, Bakersfield, CA, is seeking a Registered Nurse (RN) to serve as a Utilization Review Nurse in Case Management. The role focuses on hospital utilization review, discharge planning, and ensuring compliance with state and federal regulations.

The estimated pay range is $42.6582 to $67.2165, inclusive of a 6% premium pay. Compensation may include additional differentials, incentives, and bonuses. The role may also participate in the Kern County Employees’ Retirement Plan.

• New Hire Bonus: $6,000.00
• New Hire Premium: +6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan.
• A Comprehensive Benefits Package: includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance.

Under supervision, to provide and implement a hospital utilization review and discharge planning program; and to do related work as required.

Positions in this classification are assigned to the Utilization Review division of Kern Medical Center. Incumbents perform clinically oriented medical chart reviews and other administrative tasks to meet the requirements of the medical center’s utilization review plan, state and federal regulations, insurance company requirements for reimbursement and facility accreditation standards.

• 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.
• Initiates and completes Disease Related Groups (DRG's) for Medicare payment; answers questions from providers regarding reimbursement, prior authorization and other documentation requirements.
• Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital.
• May assist in training of other Utilization Review Nurses.
• Keeps informed of patient disease processes and treatment modalities.

• Performs other job related duties as required.

Possession of a valid license as a Registered Nurse in the State of California and two (2) years of experience as a registered nurse in an acute care hospital, at least one of which was on a medical/surgical ward or unit, OR possession of a valid license as a Registered Nurse in the State of California and 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.

Incumbents may be required to possess and maintain specific certificates. All candidates must hold an American Heart Association Provider Basic Life Support (BLS) card or complete appropriate training and obtain RQI Provider certification within 60 days of employment, and maintain certification thereafter.

• Payor source documentation requirements and governmental regulations affecting reimbursement.
• Acute care nursing principles, methods and commonly used procedures.
• Common patient…