RN Utilization Review Specialist: Care Quality & Compliance

CommonSpirit Health; Long Beach (CA); On-site; USD 168,199,000 - 210,034,000; Full time

Job summary

Dignity Health - St. Mary Medical Center in Long Beach, CA is hiring an Utilization Review Nurse to safeguard care quality and resource use.

You will review records, authorize services, and prepare cases for physician review with UM teams to ensure appropriate, cost-effective care. The role requires a strong clinical background, UM/regulatory knowledge, and excellent communication and organizational skills.

Qualifications

• 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.

Responsibilities

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.
• Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Skills

RN License

Critical Thinking

Communication Skills

Regulatory Knowledge

Education

Bachelor's degree in Nursing (BSN)

Master's degree in Case Management or Nursing

Job description

Dignity Health - St. Mary Medical Center in Long Beach, CA is hiring an Utilization Review Nurse to safeguard care quality and resource use.

You will review records, authorize services, and prepare cases for physician review with UM teams to ensure appropriate, cost-effective care. The role requires a strong clinical background, UM/regulatory knowledge, and excellent communication and organizational skills.