Utilization Review Nurse

Where You'll Work Founded in 1967, Dignity Health - Mercy San Juan Medical Center is a 377-bed, acute care, nonprofit hospital located in Carmichael, California. Serving over 100,000 patients annually, the hospital offers a full complement of services including a Level II Trauma Center, Level III NICU, heart care, cancer care, women's health, and neurology. Additionally, Mercy San Juan Medical Center has been recognized as an LGBTQ+ Healthcare Equality Leader by the Human Rights Campaign Foundation. It is a Comprehensive Stroke Center, the highest level of stroke care certification awarded by The Joint Commission. One Community. One Mission. One California Job Summary and Responsibilities The Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization.

In this position the incumbent:

Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Essential Responsibilities:

Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. Collaborates with facility RN Care Coordinators to ensure progression of care. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. Communicates the need for proper notifications and education in alignment with status changes. Engages with Denials RN or Revenue cycle vendor to identify priorities on concurrent denials based on payer timeframes. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed. Participates regularly in performance improvement teams and programs as necessary.

Job Requirements Minimum:

Two (2) years of acute hospital clinical experience A Masters degree in Case Management or Nursing field in lieu of 1 year experience. Current CA RN licensure Graduate of an accredited school of nursing

Preferred:

Bachelor's Degree in Nursing (BSN)) or related healthcare field At least five (5) years of nursing experience. Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification Knowledge to be successful in the role: Understand how utilization management and case management programs integrate Knowledge of CMS standards and requirements Highly organized with excellent time management skills and proficient in prioritizing work and delegation. Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used Proficient in application of clinical guidelines (MCG/InterQual) preferred Knowledge of managed care and payer environment preferred Must have critical thinking and problem-solving skills Communicate/Collaborate effectively with multiple stakeholders Thrive in a fast paced, self-directed environment and ability to work as a team player and assist other members where needed.