RN Case Management Utilization Review
Bakersfield, CA
Host Healthcare
3x12 hrs, Days
Referral Bonus

Job Opportunity: RN-Case Management (Utilization Review)

Location: Bakersfield, California
Employment Type: Clinical Nursing Travel
Contract Length: 13 weeks

Job Description

• Perform utilization review and discharge planning activities at a fully experienced (Level II) capacity.
• Obtain and evaluate medical records for inpatient admissions to ensure required documentation is present.
• Initiate Physician Advisories for unwarranted admissions as needed.
• Conduct ongoing reviews and discuss care changes with attending physicians and other healthcare providers.
• Formulate and document discharge plans.
• Provide consultation and coordination with multiple hospital services to ensure efficient use of resources.
• Identify pay source issues and intervene for appropriate referrals.
• Coordinate with admitting office to prevent inappropriate admissions.
• Schedule specialized tests and authorize payments under relevant programs.
• Review and approve surgery schedules to ensure elective procedures are authorized.
• Coordinate with correctional facilities regarding elective procedures and durable medical goods.
• Respond to provider questions about reimbursement, prior authorization, and documentation requirements.
• Teach providers documentation requirements to maximize reimbursement.
• May assist in training Utilization Review Nurse I staff.

Required Qualifications

• Valid Registered Nurse (RN) license in California.
• Experience:

  • Minimum 2 years as a registered nurse in an acute care hospital, with at least 1 year on a medical/surgical ward or unit.
  • Minimum 1 year of utilization review experience using InterQual guidelines.
  • OR 2 years of experience as a Case Manager in an alternate medical setting (clinic or physician’s office) performing utilization review or discharge planning.
• Knowledge of payor source documentation requirements and governmental reimbursement regulations.
• Ability to evaluate medical records for continuing stay necessity, appropriateness of care, and discharge planning.
• Strong communication skills to effectively interact with physicians, providers, payor sources, and the public.
• Ability to teach documentation requirements to co-workers.
• Current American Heart Association Healthcare Provider Basic Life Support (BLS) certification or must obtain within 60 days of employment.

Preferred Qualifications

• 1 year of Emergency Department (ED) Case Management experience.

Additional Information

• May require possession and maintenance of specific certificates based on unit requirements.
• Knowledge of acute care nursing principles, medical terminology, hospital routines, and clinical/diagnostic services is essential.