RN Utilization Review

Founded as a faith-based hospital in 1931 by the Sisters of Charity of the Incarnate Word Dignity Health St. Bernardine Medical Center is a 342-bed acute care nonprofit hospital located in San Bernardino California. The hospital offers a full complement of services including the Inland Empire Heart and Vascular Institute an award-winning orthopedics program surgical weight loss and is an official Neurovascular Stroke Center as designated by ICEMA. The hospital shares a legacy of humankindness with Dignity Health one of the nations five largest health care systems. Visit here for more information.

One Community. One Mission. One California

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician consultants second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Remote. Must reside within driving distance to San Bernardino CA.

• 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.
• California RN license.
• AHA BLS
• 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 and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Preferred

• Graduate of an accredited school of nursing (Bachelors Degree in Nursing (BSN)) or related healthcare field.
• At least five (5) years of nursing experience.
• Certified Case Manager (CCM) Accredited Case Manager (ACM-RN) or UM Certification