Job Description

Utilization Review Nurse Coord - Case Management

SUMMARY: The Utilization Review Nurse Coordinator is accountable for oversight of the Utilization Management program at Children's Hospital, under the direction of department leadership. Under minimal supervision, the UR Nurse Coordinator reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. The position combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, the coordinator will facilitate the quality of health care delivery in the most cost effective manner. The coordinator will ensure compliance with all regulations related to Utilization Management, will develop quarterly reports for the U.M. Medical Director for presentation at PT&U committee, and will facilitate UM subcommittee meetings.

JOB REQUIREMENTS: This position requires a) Two-year degree in Nursing, Bachelor's degree in related field highly desirable. b) RN License c) Minimum of 5 years full time equivalent RN experience in an acute care hospital. Prefer pediatric experience. Experience to include minimum of 2 years experience in Case Management and Utilization Review with increasingly responsible experience which demonstrates proficiency in the skill and knowledge required to perform the job. Thorough knowledge of pediatrics. Thorough knowledge of regulatory standards related to Utilization Management. Knowledge of private and public payer reimbursement practices and procedures. Proficiency with word processing, spreadsheets and database software. Excellent organizational and communication skills and ability to work with a variety of health care professionals. Ability to work independently. Prefer candidates with knowledge of and experience with Utilization Management regulations and DRG management.

POSITION DETAILS: Full Time, Days, 80 hours per 2-week pay period

LOCATION: Madera, CA

Application Instructions

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