Travel RN Case Manager - Utilization Review

Job description Certification Details- BLS California RN License Job Details- Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities. Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. Conducts on-going reviews and discusses care changes with attending physicians and others. Formulates and documents discharge plans. Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources. Identifies pay source problems and provides intervention for appropriate referrals. Coordinates with admitting office to avoid inappropriate admissions. Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary. Reviews and approves surgery schedule to ensure elective procedures are authorized. Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services. Answers questions from providers regarding reimbursement, prior authorization and other documentation requirements. Learns the documentation requirements of payor sources to maximize reimbursement to the hospital. Keeps informed of patient disease processes and treatment modalities. Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. May assist in training Utilization Review Nurse I workers. Performs other job-related duties as assigned. Job Requirements- Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital. At least one (1) year of experience must be on a medical/surgical ward or unit. One (1) year of utilization review/discharge planning experience in an acute care hospital OR two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician's office performing utilization review or discharge planning. Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement. Knowledge of acute care nursing principles, methods and commonly used procedures. Knowledge of common patient disease processes and the usual methods for treating them. Knowledge of medical terminology, hospital routine and commonly used equipment. Knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services. Ability to effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans. Ability to assess and judge the clinical performance of physicians and other health professionals. Ability to communicate documentation needs in an effective and tactful manner that promotes cooperation. Ability to teach co-workers what is needed and required in the medical record for reimbursement and audit purposes. Ability to gather and analyze data and prepare reports and recommendations based thereon. Ability to get along with physicians, other health providers, outside payor sources and the general public. Schedule Information- 8 hour Day shift.

Additional Details- California experience required. Must have experience with utilization review and InterQual Guidelines. Keywords training-certification planning-and-forecasting electrical-engineering-and-planning planning-and-design discharge-planning medical-facilities-services youth-organizations-resources environment-health-and-safety-hsse health-care healthcare-providers education-training training-and-development acute-care laws-and-regulations clubs-organizations patient-medical-record audits lift-and-shift