Utilization Review Nurse - Case Management PM Shift

Utilization Review Nurse
- Case Management
- Full Time - PM Shift

Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care.

Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year.

Position:
Utilization Review Nurse
- Full Time

Shift: 7:00PM - 7:30AM

Compensation:
The estimated pay for this position is $43.5114 to $68.5608. The rates shown include a 6% premium pay (base= $-$ plus 6%). This reflects only a portion of the total compensation package for this position. Additional compensation may be available for this role through differentials, incentives, and bonuses. In addition, this position may be eligible for participation and company contributions into the Kern County Employees' Retirement Plan.

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. The Utilization Review Nurse classification ranges from less experienced nurses, who will perform administrative tasks concerning Utilization Review and Discharge planning activities, to experienced nurses who will apply full working knowledge of applicable regulations and to develop knowledge of outside agencies and services to develop appropriate discharge plans.

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

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 or its equivalent 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 competency based on unit specific requirements as a condition of employment.

Appointees not possessing the American Heart Association Provider Basic Life Support (BLS) card at time of hire must successfully complete appropriate training and qualify for the RQI Provider certification within 60 days of employment. As a continued condition of employment, employee must maintain RQI Provider certification and competency.

Payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient…