Utilization Review RN II, Care Coordination, Full-Time, Days

MarinHealth; Greenbrae Boardwalk (CA); On-site; USD 91,000 - 136,000; Full time

Job summary

MarinHealth seeks an experienced Utilization Review Nurse to perform admission, concurrent, and retrospective reviews for designated health plans. This role ensures appropriate criteria are applied and coordinates care transfers as needed within MarinHealth.

The UR nurse will handle initial RAC reviews, escalate to Medical Director as needed, and review denials with the case management team. A BSN and active RN license are required.

Qualifications

• Bachelor of Science in Nursing preferred.
• Active RN license required at hire.
• Three+ years in acute care setting preferred.

Responsibilities

• Perform admission, concurrent and retrospective reviews for designated health plans.
• Assess clinical stability and coordinate transfers back to MarinHealth.
• Submit RAC reviews and appeal denials as required.

Skills

RN clinical care

Communication

Team collaboration

Critical thinking

Education

Bachelor of Science in Nursing

Registered Nurse license

Tools

Electronic Health Records

Microsoft Office

Job description

ABOUT MARINHEALTH

Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital’s personalized, caring touch.

MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others.

Company:

Marin General Hospital dba MarinHealth Medical Center

Compensation Range:

$66.03 - $99.04

Work Shift:

10 Hour (days) (United States of America)

Scheduled Weekly Hours:

40

Job Description Summary:

The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will elevate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.

Job Requirements, Prerequisites and Essential Functions:

EDUCATION

Bachelor of Science degree in Nursing preferred

EXPERIENCE

1. Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care.
2. Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred.
3. Experience in applying evidence based criteria related to utilization management.
4. Experience using case management software

LICENSURE AND CERTIFICATIONS

Registered Nurse Required at hire
Basic Life Support Required at hire

PREREQUISITE SKILLS

1. Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
2. Able to carry out review function and access medical records.
3. Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities.
4. Utilization review/discharge planning services appropriate to patients with complex
5. Strong attention to detail and accuracy is required.
6. Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities.
7. Demonstrated ability to work constructively with a broad spectrum of health care professionals is required.
8. Must be assertive and creative in problem solving, system planning and management.
9. Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products.

Accommodation:

Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or [e-mail].

C.A.R.E.S. Standards:

MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues.

Health & Immunizations:

To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law.

Compensation:

The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements.

Equal Employment:

All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.