Utilization Review RN

Requisition ID
2025-419247
Department
Utilization Review
Hours / Pay Period
80
Shift
Day
Standard Hours
Weekdays and everyother weekend
Location
CA-BAKERSFIELD
Posted Pay Range
$43.59 - $75.64 /hour

Overview

Bakersfield Memorial Hospital includes 385 general acute beds, 48 licensed critical care beds, 13 state-of-the-art surgical suites, and a full-service Emergency Department with an Accredited Chest Pain Center and Nationally Certified Stroke Center. In addition, we offer a beautiful Family Care and Birthing Center, the Lauren Small Children's Center including the area's only Pediatric Intensive Care Unit, Family Care Center, a Level II NICU, the Sarvanand Heart, and Brain Center with Kern County's first Bi-Plane Interventional Suite, the Center for Wound Care and Hyperbarics, and many more services. Memorial Hospital is a Children’s Miracle Network Hospital and is home to the Bakersfield Ronald McDonald House. Memorial Hospital is a member of Dignity Health and is a trusted community partner, serving residents of Bakersfield and Kern County with quality, compassionate care since 1956. Click here to learn more about Bakersfield Memorial Hospital.

One Community. One Mission. One California 

Responsibilities

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.

Qualifications

  • 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 (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 

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