Utilization Review Coordinator

The County of Santa Clara; California (MO); On-site; USD 90,000 - 120,000; Full time

Job summary

The County of Santa Clara seeks an experienced Utilization Review RN to review, monitor and assess hospital service utilization in accordance with federal, state and county regulations and the Santa Clara Valley Healthcare Utilization Plan.

Under direction, the role administers Utilization Review procedures, maintains liaison with hospital staff across SCVH facilities, and supports multiple sites as needed.

Qualifications

• Current California RN certificate is required and must be attached to the application.
• Two years of recent acute care nursing experience are normally required.
• Utilization Review experience in acute care is desirable.

Responsibilities

• Monitor admissions and review justification for services.
• Certify patient stays and outpatient services as appropriate.
• Prepare documentation for payment and maintain records.
• Liaise with hospital staff and other departments.
• Ensure compliance with Utilization Review regulations and standards.
• Attend to concurrent reviews of inpatients and related duties.

Skills

RN certification

Clinical nursing

Utilization Review

Communication

Education

California RN license

Job description

Under direction, to review, monitor and assess utilization of hospital services; to administer Utilization Review procedures as required under federal, state, and county regulations as well as Valley Medical Center's Utilization Review plan or Public Health CCS guidelines.

Only applicants who provide proof of current certification as a Registered Nurse by the State of California, Department of Health Servicescertificate attached to their application will be accepted. All other applicants will be rejected. This recruitment is to establish an Extra-Help eligible list for the APS Psychiatric Utilization Review.

Because we serve patients throughout multiple hospitals and clinics, you may have to work at different sites. We will meet any obligations we may have when this occurs.

The Power of WE

Together, we can make a greater impact. Bringing better care and expanding healthcare services across the community.

Santa Clara Valley Healthcare (SCVH) is the second largest public health care system in California and includes three acute care hospitals, 14 clinics and 60+ specialty and sub-specialty services. Our mission is to provide high-quality, accessible healthcare and excellent service to everyone in Santa Clara County.

Santa Clara Valley Medical Center

SCVMC is a full-service tertiary acute care teaching hospital with 699 licensed beds providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as #6 Rehabilitation Hospital in the nation and #1 in the West and designated as a 2024 High Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.

O'Connor Hospital

O'Connor Hospital (OCH) is a 358 licensed bed acute care facility offering a full range of inpatient and outpatient medical, surgical and specialty programs to residents of Santa Clara County. It was founded in 1889 as one of the first hospitals in the county. OCH has grown significantly over the past five years in both its inpatient volume and its Emergency Department visits. Along with these volume increases other ancillary and clinical departments like imaging, lab, pharmacy, and respiratory have seen growth as well.

St. Louise Regional Hospital

Since 1989, St. Louise Regional Hospital (SLRH) has been caring for the residents in Santa Clara and San Benito Counties, offering a wide range of inpatient and outpatient medical specialties. SLRH has 93 beds, is a Designated Primary Stroke Center, and is the only acute care hospital in the area. Located in Gilroy, SLRH maintains a CALSTAR 2 emergency helicopter base on the premises.

Regional Medical Center

RMC is a 258-bed hospital that is the main emergency healthcare provider for East San José, treating a wide range of critical and life-threatening conditions for more than 60 years. Since the SCVH integration of RMC effective 4/1/25, RMC has expanded the critical services including Level II trauma, Thrombectomy capable Stroke Center and STEMI care, and has been seeing an increased number of emergency visits and inpatient volume.

Learn more about Santa Clara Valley Healthcare: https://www.scvh.org/home and follow us on: LinkedIn|www.linkedin.com/company/county-of-santa-clara/

• Monitors admissions of patients for hospital care;
• Reviews justification for services;
• Reviews and certifies patient stays, need for acute hospitalization and/or indicated outpatient services, and need for length of stay extensions;
• Prepares documentation related to appropriate payment for services;
• Maintains close liaison with all levels of professional hospital staff;
• Maintains liaison with other county departments and outside health care agencies;
• Investigates and documents rejected insurance claims;
• Participates in and provides assistance with patient audit activities;
• Facilitates compliance with Utilization Review regulations;
• Conducts concurrent review of all inpatients;
• Traces medical billings to be paid;
• Acts as resource in referral of outpatient discharges;
• Prepares and maintains appropriate records and/or documents and submits reports as required;
• Maintains a working knowledge of current regulations affecting patient care services and related fiscal programs;
• May assist in preparation of billing claims;
• May perform the above duties and provide medical case management primarily in relation to patients under the California Childrens Services program;
• Performs other related duties as assigned.

Possession of a current California RN license.

Experience Note: The knowledge and abilities required would normally be acquired by two (2) years of recent nursing experience in an acute care hospital setting. Utilization Review experience in an acute care setting is desirable.

Knowledge of:

• Hospital organization, operations and procedures;
• Federal and state health care laws and regulations common to the operation of hospitals in California;
• Regulations of intermediary agencies pertaining to hospital stay coverage (e.g. Medicare and Medi-Cal);
• Medical terminology and related levels of care and treatment;
• Data processing systems as relating to Utilization Review;
• Evaluation and assessment techniques;
• Record keeping and reporting procedures.

Ability to:

• Maintain effective reporting systems;
• Collect and record data;
• Interact with all levels of hospital staff;
• Maintain close liaison with hospital resources;
• Interpret health care laws, regulations and procedures;
• Evaluate data and statistics;
• Work independently;
• Communicate effectively orally and in writing.