Utilization Review Nurse II

Kaiser Permanente; Reno (NV); Remote; USD 90,000 - 120,000; Full time

Job summary

Kaiser Permanente in Reno, Nevada, is seeking an experienced Utilization Review Nurse II to support clinical reviews, coordinate care, and guide decisions on medical necessity and duration of treatment.

You will collaborate with physicians, care teams, and members to optimize cost of care, assist discharge planning, and ensure alignment with evidence-based guidelines. A Nevada RN license and utilization review experience are required.

Qualifications

• Bachelor's Degree in Nursing and at least 1 year of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a related field.
• Registered Nurse License (Nevada) required at hire.
• Utilization review/management experience preferred.

Responsibilities

• Pursues effective relationships with others by sharing resources and knowledge; listens and responds to feedback; adapts to change.
• Completes work by applying up-to-date knowledge to meet deadlines; follows procedures and supports projects with limited guidance.
• Supports high-quality consultation by communicating on requirements Related to medical necessity and benefit denials across care continuum.
• Supports education and compliance initiatives by staying up-to-date with relevant regulations and guidelines.
• Assists in quality improvement by observing utilization patterns and adhering to utilization policies and workflows.
• Performs utilization reviews by following standard policies to evaluate medical necessity and efficiency of services.

Skills

Ambiguity/Uncertainty Management

Attention to Detail

Communication

Critical Thinking

Cross-Group Collaboration

Decision Making

Dependability

Diversity, Equity, and Inclusion

Drives Results

Facilitation Skills

Health Care Industry

Influencing Others

Integrity

Learning Agility

Organizational Savvy

Problem Solving

Short- and Long-term Learning

Teamwork

Topic-Specific Communication

Education

Bachelor's Degree in Nursing

Nevada RN License

Job description

REMOTE - Must currently live in Nevada.

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 (Nevada) required at hire

Preferred Qualifications:

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

COMPANY: KAISER

TITLE: Utilization Review Nurse II

LOCATION: Reno, Nevada

REQNUMBER: 1459151

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.