Utilization Review RN

Dignity Health one of the nations largest health care systems is a 22-state network of more than 9000 physicians 63000 employees and 400 care centers including hospitals urgent and occupational care imaging and surgery centers home health and primary care clinics. Headquartered in San Francisco Dignity Health is dedicated to providing compassionate high-quality and affordable patient-centered care with special attention to the poor and underserved. For more information please visit our website at . You can also follow us on Twitter and Facebook.

This position is responsible for improving care management coordination between hospital staff and affiliated medical groups and IPAs by using advanced problem-solving skills consultation communication personal education and research. This position is also responsible for providing oversight for out-of-network (OON) cases that are capitated to the Dignity Health hospitals (as well as participation in In-Network Utilization management). in the GSSJSA and to provide support to the Director Clinical Partnerships related to managing capitated business. This position works with affiliated Medical Groups and IPAs to meet appropriate quality patient satisfaction and utilization objectives in a manner consistent with the Mission and Philosophy of Dignity Health.

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Minimum:

• California RN license
• Bachelors in Nursing Business or equivalent or a combination of knowledge and experience that adequately prepares the individual to competently perform the job.
• Five (5) years experience in utilization review and discharge planning case management and managed care.

Other qualifications:

• Knowledge of thereimbursement under Medicare MediCal and private insurance capitation including Medical group/physician implication.
• Case management of capitated at-risk patients.
• Excellent interpersonal skills to effectively build relationships within and outside the organization
• Understanding of:
  JCAHO and State and Federal Regulations
  Coding documentation DRGs
  Case Management models and standards.
  Nursing theory and practice standards.
  Research models.

We prefer candidates with:

Certification in Case Management