Utilization Review RN

Overview

Marian Regional Medical Center a 191-bed facility located in Santa Maria California is recognized as one of the Top 250 Hospitals in the Nation by Healthgrades and was awarded Best Maternity Care by Newsweek. It ranks among 10% in the nation for safety core measures in cardiac services and has the only comprehensive cancer treatment and resource program from Los Angeles to San Francisco. Marian’s beautiful mission-style facility houses the latest technology to support excellent physicians and caregivers who deliver compassionate care each and every day. Marian Regional Medical Center is a part of Dignity Health’s Southwest Division and is a member of CommonSpirit Health the largest not-for-profit health care system in the nation boasting an integrated network of top quality hospitals with physicians from the most prestigious medical schools and comprehensive outpatient services - all recognized for quality safety and service. Marians offers Santa Maria Valley residents access to the most advanced technologies an expanded and enhanced Emergency Department Critical Care Unit neonatal intensive care unit and an array of womens services.

Responsibilities

JOB SUMMARY / PURPOSEResponsible for the review of medical records for appropriate admission status and continued hospitalization. Workcollaboration with the attending physician, consultants, second level physician reviewer and the Care Coordinationutilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine theroot cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verifythe correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or providesclinical guidance to Payer Communications staff to support communication with the insurance providers to obtainadmission and continued stay authorizations as required within the market.

Qualifications

Required Education and Experience

● Graduate of an accredited school of nursing● Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience

Required Licensure and Certifications

● RN: CA

Required Minimum Knowledge, Skills, Abilities, and Training

● Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used● Proficient in application of clinical guidelines(MCG/InterQual) preferred● Knowledge of managed care and payer environment preferred.● Must have critical thinking and problem-solving skills.● Collaborate effectively with multiple stakeholders● Professional communication skills● Understand how utilization management andmanagement programs integrate.● Ability to work as a team player and assist other membersof the team where needed.● Thrive in a fast paced, self-directed environment.● Knowledge of CMS standards and requirements.● Proficient in prioritizing work and delegating whereindicated.● Highly organized with excellent time management skills

Preferred Education and Experience

Bachelor's Degree in Nursing (BSN) or related healthcarefield

At least five (5) years of nursing experience

Preferred Licensure and Certifications

Certified Case Manager (CCM), Accredited Case Manager(ACM-RN), or UM Certification preferred