Utilization Review​/Case Management RN

Job Overview

Immediate need for a talented Utilization Review/Case Management RN
. This is a 03+ Months Contract opportunity with long‑term potential and is located in Santa Clara, CA (Onsite). Pay Range: $75 - $85/hour. Employee benefits include health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location). Job
-96149.

• Utilization Management:
  Performs daily pre‑admission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge.
• Monitors the progression of the discharge plan and facilitates discussions with the multidisciplinary teams.
• Educates other healthcare team members on utilization and care coordination.
• Collaborates with and provides information to patients, families, physicians, and staff regarding the discharge plans and transitions.
• Understands and consistently applies the interpretation and utilization of member health care benefits.
• Conducts UM, care coordination and discharge planning activities according to all applicable regulatory requirements.
• Discharge Planning:
  Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
• Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other health care providers and agencies.
• Regulatory:
  Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements.
• Shift Timings: 8:00 AM – 4:30 PM – 5 days/week including every other weekend (both Saturday & Sunday).
• Days vary but we are looking for 2 travelers to fill the schedules below:
• Traveler
  Week 1 Schedule
  Week 2 Schedule
• Traveler 1:
  Mon, Tue, Wed, Fri, Sat – Sun, Mon, Wed, Thu, Fri
• Traveler 2:
  Mon, Tue, Thu, Fri, Sat – Sun, Tue, Wed, Thu, Fri

• Skills
  :
  Recent hospital/acute care setting experience.
• Strong discharge planning background.
• Availability aligned with the outlined shift schedules.
• Minimum two (2) years of experience in utilization review, case management, and discharge planning.
• Graduate of accredited school of nursing.
• Diploma/Associate Degree in Nursing.
• License, Certification, Registration:
  Registered Nurse License (California) – Required upon hire.
• Basic Life Support (BLS) – Required upon hire.
• Knowledge of the Nurse Practice Act, TJC, DMHC, CMS, NCQA, HIPAA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.
• Demonstrated strong communication and customer service skills, problem‑solving, critical thinking, & clinical judgment abilities.
• Fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day to day operations.
• Knowledge of health care benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi‑Cal, Federal, etc.).
• Must be able to work in a Labor/Management Partnership environment.
• Acute inpatient hospital-level experience.
• Bachelor's degree in nursing or a health care related field preferred.
• Master's degree in case management preferred.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.