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RN-Case Management (Utilization Review)

Integrated Resources, Inc

Bakersfield, CA

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JOB DETAILS
JOB TYPE
Contractor
SKILLS
Acute Care, Case Management, Communication Skills, Data Analysis, Data Collection, Discharge Plans, Disease, Documentation, Documentation Plan, Government Regulations, Government Requirements, Healthcare Providers, Hospital, Identify Issues, Medical Office, Medical Records, Medical Terminology, Medical Treatment, Medicine, Nursing, Patient Admissions, Patient Assessment, Registered Nurse (RN), Reimbursement, Reporting Skills, Training/Teaching, Utilization Management
LOCATION
Bakersfield, CA
POSTED
7 days ago
Job Summary: Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities. Job Responsibilities: -Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. -Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. -Conducts on-going reviews and discusses care changes with attending physicians and others. -Formulates and documents discharge plans. -Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources. -Identifies pay source problems and provides intervention for appropriate referrals. -Coordinates with admitting office to avoid inappropriate admissions. -Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary. -Reviews and approves surgery schedule to ensure elective procedures are authorized. -Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services. -Answers questions from providers regarding reimbursement, prior authorization and other documentation requirements. -Learns the documentation requirements of payor sources to maximize reimbursement to the hospital. -Keeps informed of patient disease processes and treatment modalities. -Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. -May assist in training Utilization Review Nurse I workers. -Performs other job-related duties as assigned. Required Skills & Experience: -(Level I) Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital. -At least one (1) year of experience must be on a medical/surgical ward or unit. -(Level II) One (1) year of utilization review/discharge planning experience in an acute care hospital. OR -Two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physicians office performing utilization review or discharge planning. -Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement. -Knowledge of acute care nursing principles, methods and commonly used procedures. -Knowledge of common patient disease processes and the usual methods for treating them. -Knowledge of medical terminology, hospital routine and commonly used equipment. -Knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services. -Ability to effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans. -Ability to assess and judge the clinical performance of physicians and other health professionals. -Ability to communicate documentation needs in an effective and tactful manner that promotes cooperation. -Ability to teach co-workers what is needed and required in the medical record for reimbursement and audit purposes. -Ability to gather and analyze data and prepare reports and recommendations based thereon. -Ability to get along with physicians, other health providers, outside payor sources and the general public. Preferred Skills & Experience: -N/A

About the Company

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Integrated Resources, Inc

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