Utilization Review RN (Hybrid)

Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required.

Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly.

Education

• • Valid RN license in State of California
  • Bachelor's degree in Nursing

Experience

• • • Clinical experience in acute care setting Required
    • Experience with interqual and millimen Preferred

Licenses and Certifications

• • • • CPR - Cardiac Pulmonary Resuscitation CPR/BLS Preferred and
      • CCM - Certified Case Manager CCM Preferred and
      • ACMA Preferred

Knowledge, Skills, and Abilities

• • • • Verbal and written communication skills.
      • Basic computer skills.
      • Diagnostic and problem-solving skills.
      • Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
      • Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs.
      • Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate.
      • Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care.
      • Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity.
      • Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission.
      • Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team.
      • Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.
      • Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.
      • Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations.
      • Performs other duties as assigned.