Utilization Review Nurse

Nestled in the heart of East Sacramento, Dignity Health Mercy General Hospital is a 313 bed acute care facility that provides a wide range of services with special advocacy for the poor and underserved. Mercy General is home to the nationally ranked Alex G. Spanos Heart & Vascular Institute. Key achievements and recognitions include: from the Joint Commission; Advanced Joint Replacement, Spine Center of Excellence Primary Stroke Center, Ventricular Assist Device, and Chest Pain Certification. Other accolades include CMS 5 stars, Practice Green Health 2021, Leapfrog Hospital Safety Grade "A", Level 4 Epilepsy Center and Opioid Stewardship Honor Roll. Mercy General Hospital is proud to foster inclusion and diversity as part of our mission, vision, and values.  

One Community. One Mission. One California 

The Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. In this position the incumbent: 

• 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.

Essential Responsibilities:

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.

• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.

• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.

• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.

• Collaborates with facility RN Care Coordinators to ensure progression of care.

• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

• Communicates the need for proper notifications and education in alignment with status changes.

• Engages with Denials RN or Revenue cycle vendor to identify priorities on concurrent denials based on payer timeframes.

• Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.

• Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.

• Participates regularly in performance improvement teams and programs as necessary.

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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.

• Current CA RN licensure

Preferred: 

• Bachelor's 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 

Knowledge to be successful in the role: 

• Understand how utilization management and case management programs integrate

• Knowledge of CMS standards and requirements

• Highly organized with excellent time management skills and proficient in prioritizing work and delegation.

• 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

• Communicate/Collaborate effectively with multiple stakeholders

• Thrive in a fast paced, self-directed environment and ability to work as a team player and assist other members where needed.