Job Title: RN - Case Management (Utilization Review)

Location: California

Employment Type: Full-Time

Contract Length: Permanent

Job Summary: The Utilization Review Nurse II is responsible for evaluating medical records, discharge planning, and ensuring efficient use of hospital resources while maximizing reimbursement.

Job Responsibilities:

• Evaluate medical records for inpatient admissions to ensure required documentation is present.
• Initiate Physician Advisories for unwarranted admissions and obtain records as required by payor agencies.
• Conduct ongoing reviews and discuss care changes with attending physicians.
• Formulate and document discharge plans.
• Coordinate with hospital services to ensure efficient resource utilization.
• Identify pay source issues and provide appropriate referrals.
• Collaborate with admitting offices to prevent inappropriate admissions.
• Schedule specialized tests and authorize payments under the Medically Indigent Adult program.
• Review and approve surgery schedules for elective procedures.
• Coordinate with correctional facilities regarding elective procedures and durable medical goods.
• Answer provider questions about reimbursement, prior authorization, and documentation requirements.
• Teach providers payor source documentation requirements to maximize hospital reimbursement.
• Assist in training Utilization Review Nurse I workers.
• Perform other job-related duties as assigned.

Required Qualifications:

• Two (2) years of experience as an RN in an acute care hospital, with at least one (1) year 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 as a Case Manager in a clinic or physician’s office performing utilization review/discharge planning.
• Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement.
• Understanding of acute care nursing principles, methods, and procedures.
• Familiarity with common patient disease processes and treatment methods.
• Proficiency in medical terminology, hospital routines, and commonly used equipment.
• Ability to evaluate medical records, assess clinical performance, and communicate documentation needs effectively.
• Capability to teach co-workers about medical record requirements for reimbursement and audits.
• Strong analytical skills for data gathering and report preparation.
• Ability to collaborate with physicians, health providers, payor sources, and the public.

Required Certifications & Licensure:

• Valid Registered Nurse license in the State of California.
• Current American Heart Association Healthcare Provider Basic Life Support (BLS) card.

Preferred Qualifications:

• None specified.

Additional Information: Highest level of education as stated on the resume.