Utilization Review Nurse II

Kaiser Permanente; Baldwin Park (CA); In loco; USD 90.000 - 120.000; Tempo pieno

Descrizione del lavoro

Kaiser Permanente in California seeks a Registered Nurse with utilization review experience to consult on medical necessity and level of care across the care continuum. You will collaborate with physicians, managers, and care teams to optimize discharge planning and cost-of-care options.

The role emphasizes evidence-based practice, adherence to guidelines, and ongoing participation in education programs for staff and physicians within the local utilization management framework.

Competenze

• Bachelors Degree in Nursing and CA RN license required.
• Minimum one year of experience in direct patient care, utilization review/management, or discharge planning.
• Experience in managed care setting preferred.

Mansioni

• Build effective relationships by sharing resources and knowledge with coworkers and members; respond to feedback.
• Complete work by using current subject knowledge to meet deadlines and follow procedures.
• Consult on medical necessity and benefit denials across the continuum of care with physicians, managers, staff, members, and caregivers.
• Support education by staying up-to-date with state and federal regulations and participating in training programs.
• Contribute to quality improvement by identifying utilization patterns and opportunities for improvement.
• Perform utilization reviews by following policies to evaluate medical necessity and efficiency of services.

Conoscenze

Communication

Critical Thinking

Problem Solving

Teamwork

Decision Making

Health Care Industry

Formazione

Bachelor's Degree in Nursing

RN License (California)

Descrizione del lavoro

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for leveraging clinical knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the medical necessity, level of care, and duration of treatment required for standard reviews, and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating referrals to appropriate services based on medical necessity.

Essential Responsibilities:

• Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome.
• Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
• Supports high-quality consultation by: communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently; and leveraging working knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
• Supports education and compliance initiatives by: remaining up-to-date and discussing with the team the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and participating and providing feedback on education and training programs for staff and physicians at the local level to promote best practices in utilization management.
• Assists in quality improvement efforts by: observing and identifying utilization patterns, trends, and opportunities for improvement; learning about utilization review workflows/processes including corrective action plans and standard work, and identifying deficiencies in workflows; and learning and actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care.
• Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services, under guidance; and assessing the ongoing need for services, identifying potential issues/delays, and recommending appropriate actions for standard member cases.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Teamwork
• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Medical Terminology
• Nursing Principles
• Acts with Compassion
• Confidentiality
• Consulting
• Evidence-Based Medicine Principles
• Quality Assurance and Effectiveness
• Relationship Building
• Written Communication

Minimum Qualifications:

• Bachelors Degree in Nursing AND minimum one (1) year of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a directly related field.

• Registered Nurse License (California) required at hire

Preferred Qualifications:

• One (1) year of experience in utilization review/management.