Utilization Review RN (Case Management)
Bakersfield, California
Kern Medical Center

Job Opportunity: RN-Case Management (Utilization Review)

Job Summary

This position is for a Utilization Review Nurse II, representing a fully experienced level in utilization review and discharge planning activities. The role involves evaluating medical records for inpatient admissions, coordinating care changes with physicians, formulating discharge plans, and ensuring efficient use of hospital resources. The nurse will also handle payor source documentation, authorization of procedures, and provide education on documentation requirements to providers and staff.

Key Responsibilities

• Obtain and 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 multiple hospital services to optimize resource use.
• Identify pay source issues and provide appropriate referrals.
• Coordinate with admitting offices and clinics to avoid inappropriate admissions and authorize payments.
• Review and approve surgery schedules to ensure elective procedures are authorized.
• Collaborate with correctional facilities regarding elective procedures and durable medical goods.
• Answer provider questions about reimbursement, prior authorization, and documentation.
• Teach providers and staff about payor documentation requirements to maximize reimbursement.
• Assist in training Utilization Review Nurse I staff.
• Stay informed about patient disease processes and treatment modalities.

Required Qualifications

• Valid Registered Nurse (RN) license in California.
• Associate of Science in Nursing (ASN) or Associate Degree in Nursing (ADN).
• At least 1 year of case management experience, with case management experience within the last year.
• Experience in utilization review, including knowledge of InterQual criteria.
• Experience in discharge planning.
• Acute hospital case management experience.
• Utilization review experience.

Contract Length

• Approximately 13 weeks (88 days rounded to 13 weeks).

Prior Travel Experience

• Not explicitly required.

This role is ideal for experienced RNs with a strong background in utilization review, discharge planning, and case management within acute care settings, especially those familiar with California healthcare systems.