Clinical Utilization Review Nurse II (Per Diem, Variable)

Northbay Healthcare

Fairfield, CA

Apply

JOB DETAILS

JOB TYPE

Full-time

SKILLS

Acute Care, Adobe Product Family, American Nurses Credentialing Center (ANCC), Analysis Skills, Cancer, Cardiovascular, Case Management, Cerner, Certified Case Manager (CCM), Clinical Competency, Clinical Information, Clinical Nursing, Clinical Study Publications, Communication Skills, Compensation and Benefits, Computer Skills, Contract Requirements, Corrective Action, Customer Service Software, Data Entry, Data Quality, Documentation, Documentation Review, Electronic Medical Records, English Language, Establish Priorities, Federal Laws and Regulations, Frequently Asked Questions (FAQ), Healthcare, Healthcare Reimbursement, Hospital, Interpersonal Skills, Leadership, Managed Care, Medicaid, Medicare, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Neonatal Intensive Care Unit (NICU), Neuroscience, Nonprofit, Nursing Credentials, Organizational Skills, Orthopedics, Outpatient Care, Patient Care, Patient Safety, Performance Analysis, Performance Management, Performance Reviews, Primary Care, Problem Solving Skills, Process Improvement, Quality Assurance, Quality Management, Registered Nurse (RN), Regulations, Requirements Management, Risk, Surgical Procedures, Team Player, Time Management, Training/Teaching, Trend Analysis, Urgent Care, Utilization Management, Work From Home

LOCATION

Fairfield, CA

POSTED

4 days ago

At NorthBay Health the Clinical Utilization Review Nurse II (URN) is an experienced registered nurse who prospectively and concurrently evaluates appropriateness of inpatient and observation services based on clinical documentation, evidence-based guidelines and insurance benefits, and communicates required clinical information to payers in accordance with contractual and regulatory obligations. The Level II URN serves as a clinical resource to physicians/providers by providing education related to medical necessity, utilization review and payer requirements.PRIMARY JOB DUTIESPerform comprehensive admission and continued-stay reviews for inpatient and observation cases using facility-approved criteria and payer rules.Ensure utilization review documentation is accurate, timely and audit-ready, clearly reflecting clinical facts, criteria application and rationale.Identify opportunities for alternative levels of care when criteria are not met.Identify short-stay risk, disputed status and medical necessity concerns and escalate to Physician Advisor or leadership as indicated.Oversee and ensure the Daily Review Tracker, Ambulatory Surgery list and Observation-to-Inpatient list are consistently maintained, updated and reviewed in a timely manner; validates data integrity, identifies gaps or delays and initiates corrective action as needed.Prepare concise clinical summaries for peer-to-peer discussions and payer communications.Monitor and report denial trends, avoidable days and utilization issues within assigned workload for continued process improvement.Collaborate with revenue cycle on claim issues and appeals.Analyze population-specific utilization patterns and communicate issues impacting progression of care.Promote use of evidence-based protocols, pathways and order sets to support high-quality and cost-effective care.Participate in audits, quality improvement initiatives, shared governance activities and ongoing competency development.Education: Graduate of an accredited school of nursing. BSN required. Licensure: Current California RN License and Magnet ANCC-recognized Case Management certification (CCM, ACM-NBCM, etc.).Experience: Minimum of 5 years of clinical nursing experience including 3 years in utilization review/case management. Advanced knowledge of Milliman Care Guidelines, Medicare/Medicaid and managed care requirements.Skills:Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments and performance evaluations.Sufficient proficiency in speaking, reading and writing the English language necessary to perform the essential functions of this job, especially regarding activities impacting patient or employee safety or security.Ability to effectively communicate with physicians and co-workers in a manner consistent with a customer service focus and application of positive language principles.Advanced knowledge of Milliman Care Guidelines and knowledge of local and national coverage determinations.Comprehensive knowledge of Medicare, Medicaid and Managed Care requirements.Comprehensive knowledge of health care financial and payer requirements/issues.Comprehensive knowledge of utilization review, case management, performance improvement, and managed care reimbursement. Ability to work independently and exercise sound judgment in interactions with physicians and health care team members. Strong assessment, organizational and problem-solving skills; strong time-management and ability to handle high-volume UR reviews without dropping documentation quality. Comfort navigating EMRs and UR documentation tools with accurate data entry and audit readiness. Maintains level of professional certification/s as required. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44). Competent computer skills in Cerner, Adobe and Microsoft Office Suite (Excel, Teams, Outlook, PowerPoint and Word)Interpersonal Skills: Demonstrates professional and respectful communication. Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction. Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position. Demonstrates a courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner. Utilizes critical thinking and applies sound clinical judgment and assessment skills for decision making.About UsInterpersonal Skills and ValuesDemonstrates NorthBay Health’s True North Values: Nurture Care, Own It, Respect Relationships, Build Trust, and Hardwire Excellence. These values guide behavior, accountability, teamwork, and commitment to high-quality patient care.Why NorthBay HealthNorthBay Health is an independent, nonprofit health system serving the Napa, Solano, and Yolo County regions. We are expanding access to care across our communities through two acute-care hospitals, including a Level II Trauma Center and a Level III NICU maternity unit, along with a cancer center, urgent care locations, and a growing network of primary and specialty care clinics.We provide advanced services in cardiovascular care, neuroscience, orthopedics, surgery, and outpatient specialties. NorthBay Health is nationally recognized for quality care, including Magnet with Distinction designation for nursing and multiple U.S. News and World Report high performing recognitions.We are committed to being the trusted healthcare partner of choice and offer an environment where employees can grow, contribute meaningfully, and support the health of our communities.NorthBay Health Benefits OptionsNorthBay Health offers a comprehensive benefits package based on established eligibility requirements. Benefits may include medical, dental, and vision insurance, life, disability, and long-term care coverage, paid time off including vacation, sick leave, holidays, and bereavement, a 403(b) retirement plan with employer match, education reimbursement for eligible roles, professional development and training programs, Employee Assistance Program, wellness programs, recognition programs, shift differentials, and market-based compensation review and increases subject to approval and organizational performance.Compensation StructureNorthBay Health uses a structured compensation framework. Staff-level positions use a step-based system (Steps 1–5) based on years of directly related experience, with Step 5 representing 20 or more years of experience in the role. Manager level and above positions are paid a fixed annual base salary and are eligible for a variable incentive compensation plan. Physician compensation is structured based on specialty and role requirements.Remote Work DisclosureNorthBay Health is primarily an onsite organization due to the nature of healthcare. Some roles may allow hybrid or remote work based on business needs.Remote work is not supported in Washington, Ohio, Wyoming, North Dakota, Puerto Rico, the U.S. Virgin Islands, or outside of the United States.Notice to Recruitment AgenciesNorthBay Health utilizes a managed service provider (MSP) for agency partnerships and is not currently engaging external recruiting firms outside of established agreements. We do not accept unsolicited resumes or third-party candidate submissions. Please do not contact NorthBay Health employees, leaders, physicians, or hiring managers regarding recruitment or job postings.More InformationVisit NorthBay Health Careers for recruitment FAQs and additional information.

About the Company

Northbay Healthcare

Resume Resources

Free Resume Templates Free Resume Builder