Job Description

Utilization Review Program Coordinator RN - 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) Associated Degree in Nursing, 4 year degree in Nursing or related field preferred b) Active CA RN license, c) Minimum 5 years experience in full time acute care nursing role or equivalent, d) pediatric experience and experience and experience in case management and/or utilization review preferred.

Thorough knowledge of pediatrics preferred. 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, 80 hours per pay period, days


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