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

Job Opportunity: RN Case Management (Utilization Review)

Location

• Bakersfield, California

Job Type

• Staffing - Supplier Sourced

Job Description

• Perform utilization review and discharge planning activities at an experienced level.
• Obtain and evaluate medical records for inpatient admissions to ensure required documentation is present.
• Obtain records as required by payor agencies and initiate Physician Advisories for unwarranted admissions.
• Conduct ongoing reviews and discuss care changes with attending physicians and other healthcare providers.
• Formulate and document discharge plans.
• Provide ongoing consultation and coordination with multiple hospital services to ensure efficient use of resources.
• Identify pay source problems and provide interventions for appropriate referrals.
• Coordinate with admitting office to avoid inappropriate admissions.
• Coordinate with clinic areas for scheduling specialized tests, assessing pay source, and authorizing payment under relevant programs.
• Review and approve surgery schedules to ensure elective procedures are authorized.
• Coordinate with correctional facilities regarding use of elective procedures, durable medical goods, and other services.
• Answer provider questions regarding reimbursement, prior authorization, and documentation requirements.
• Stay informed about patient disease processes and treatment modalities.
• Teach providers documentation requirements to maximize reimbursement.
• May assist in training less experienced Utilization Review Nurses.
• Perform other related duties as assigned.

Required Qualifications

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

  • Level I: Minimum 2 years as an RN in an acute care hospital, with at least 1 year on a medical/surgical ward or unit.
  • Level II: Minimum 1 year of utilization review/discharge planning experience in an acute care hospital or as a Case Manager in an alternate medical setting (clinic or physician’s office).
  • Alternatively, 5 years of experience as a Case Manager in an alternate medical setting performing utilization review or discharge planning.
• Possession and maintenance of current American Heart Association Healthcare Provider Basic Life Support (BLS) certification (must obtain within 60 days if not currently held).
• May require additional unit-specific certificates or competencies.

Preferred Experience

• Case management experience in California (excluding Kaiser), preferably with more than one assignment.
• Ability to perform both Utilization Review and Care Coordination/Discharge Planning.
• Experience in acute care, ICU, and Emergency Department units.
• Trauma facility experience is a plus.
• Experience working in teaching facilities is desirable.

Contract Length

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

This position is suited for experienced RNs with strong case management and utilization review skills, particularly those familiar with acute care settings and California healthcare regulations.