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 compliance with payor documentation requirements to maximize hospital reimbursement.
Job Responsibilities:
- Evaluate medical records for inpatient admissions to ensure required documentation is present.
- Initiate Physician Advisories for unwarranted admissions.
- Conduct ongoing reviews and discuss care changes with attending physicians.
- Formulate and document discharge plans.
- Coordinate with hospital services to ensure efficient resource use.
- Identify pay source issues and provide appropriate referrals.
- Collaborate with admitting office to prevent inappropriate admissions.
- Schedule specialized tests and authorize payments under Medically Indigent Adult programs.
- Review and approve surgery schedules for elective procedures.
- Coordinate with correctional facilities regarding elective procedures and durable medical goods.
- Answer provider questions about reimbursement and documentation requirements.
- Teach providers payor source documentation requirements to maximize reimbursement.
- Assist in training Utilization Review Nurse I staff.
- 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 for necessity, appropriateness, and discharge planning.
- Strong communication and teaching skills for documentation needs.
- Ability to gather and analyze data for reporting and recommendations.
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:
Additional Information: This position requires collaboration with physicians, health providers, payor sources, and the general public to ensure effective utilization review and discharge planning.
