RN Utilization Review

Santa Barbara Cottage Hospital; United States; Remote; USD 95,000 - 125,000; Full time

Job summary

A healthcare facility in California is seeking experienced nursing professionals to review medical records and ensure appropriate admission status. The role involves collaboration with various stakeholders, including physicians and Care Coordination staff, to support patient admissions. Candidates must have a valid California RN license and at least two years of clinical experience or a Master's degree in a related field. The position offers remote work with emphasis on critical thinking and problem-solving skills.

Qualifications

• Minimum two years of acute hospital clinical experience or equivalent education.
• Must have a California RN license.
• Must pass annual inter-rater reliability test.
• Knowledge of managed care and payer environments preferred.

Responsibilities

• Review medical records for appropriate admission status.
• Collaborate with physicians and Care Coordination staff.
• Establish and verify the correct payer source for patient stays.

Skills

Critical thinking

Problem-solving

Professional communication

Time management

Education

California RN license

Master's degree in Case Management or Nursing

Bachelor's Degree in Nursing (BSN)

Tools

MCG/InterQual guidelines

Job description

Where You’ll Work

Founded as a faith-based hospital in 1931 by the Sisters of Charity of the Incarnate Word, Dignity Health – St. Bernardine Medical Center is a 342-bed, acute care, nonprofit hospital located in San Bernardino, California. The hospital offers a full complement of services, including the Inland Empire Heart and Vascular Institute, an award-winning orthopedics program, surgical weight loss, and is an official Neurovascular Stroke Center, as designated by ICEMA. The hospital shares a legacy of humankindness with Dignity Health, one of the nation’s five largest health care systems. Visit https://www.dignityhealth.org/socal/locations/stbernardinemedical for more information.

One Community. One Mission. One California

Job Summary and Responsibilities

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Job Requirements

Remote. Must reside within driving distance to San Bernardino, CA.

• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• California RN license.
• AHA BLS
• Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.
• Proficient in application of clinical guidelines (MCG/InterQual) preferred
• Knowledge of managed care and payer environment preferred.
• Must have critical thinking and problem-solving skills.
• Collaborate effectively with multiple stakeholders
• Professional communication skills.
• Understand how utilization management and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced, self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Preferred

• Graduate of an accredited school of nursing (Bachelor' s Degree in Nursing (BSN)) or related healthcare field.
• At least five (5) years of nursing experience.
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification