Utilization Review RN

Overview

Dignity Health Mercy San Juan Medical Center is a 370-bed not-for-profit Level 2 Trauma Center located in Carmichael California serving the areas of north Sacramento County and south Placer County for more than 50 years.

It is one of the area’s largest and most comprehensive medical centers. Dedicated to the community’s well-being our staff and volunteers provide excellence in care for our patients each year.

Mercy San Juan Medical Center has received recognition for being a Comprehensive Stroke Center and Center of Excellence for Bariatric Surgery along with Certificates of Excellence in Perinatal Care Hip- and Knee- Replacement.

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.

We offer the following benefits to support you and your family :

Health / Dental / Vision Insurance

Flexible spending accounts

Voluntary Protection : Group Accident Critical Illness and Identity Theft

Adoption Assistance

Free Premium Membership to Care.com with preloaded credits for children and / or dependent adults

Employee Assistance Program (EAP) for you and your family

Paid Time Off (PTO)

Tuition Assistance for career growth and development

Retirement Programs

Wellness Programs

Qualifications

This is a remote position

Minimum :

Two (2) years of acute hospital clinical experience - OR - a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

Current CA RN licensure

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

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