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

Marin General Hospital dba MarinHealth Medical Center; United States; On-site; USD 91,000 - 136,000; Full time

Job summary

MarinHealth is seeking a Utilization Review Nurse to perform admission, concurrent and retrospective reviews for designated health plans. The UR nurse will apply standardized criteria and document concurrently in the patient record.

The role requires assessing clinical stability and coordinating transfers back to Marin General for continued care when patients are admitted to non-contracted facilities. A BSN is preferred with 3+ years of acute care experience.

Qualifications

• Bachelor of Science degree in Nursing preferred.
• Three+ years in acute patient care setting.
• Utilization review and discharge planning experience preferred.
• Experience using case management software.

Responsibilities

• Perform admission, concurrent and retrospective reviews for designated health plans.
• Apply standardized criteria and document concurrently.
• Assess clinical stability and coordinate transfers back to Marin General for continued care when patients are admitted to non-contracted hospitals.
• Review denials and appeal medical necessity denials.
• Escalate cases to Medical Director to ensure appropriate patient care.

Skills

Communication skills

Clinical reasoning

Team collaboration

Education

Bachelor of Science in Nursing

Tools

Electronic Health Record

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 escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.

Job Requirements, Prerequisites and Essential Functions

EDUCATION

1. 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

1. Registered Nurse Required at hire
2. 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.

Welcome and Diversity

We are Equal Opportunity Employers, and we welcome and encourage diversity in the workplace regardless of race, gender, sexual orientation, gender identity, disability or veteran status.

Accommodations

Reasonable accommodation(s) to qualified individuals with disabilities are available as part of the application step. If an accommodation is needed, please contact Human Resources at 415-925-7040 or email [e-mail] to initiate the process.