Utilization Review RN

Job ID
2021-167420
Employment Type
Full Time
Department
Utilization Review
Hours / Pay Period
80
Facility
Dignity Health Management Services Organization
Shift
Day
Standard Hours
Monday - Friday 8:00 am- 5:00 pm
Work Schedule
8 Hour
Location
CA-Redlands

Overview

 

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

 

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

Responsibilities

As a part of the Utilization Management team the Utilization Review RN is a member of the Care Coordination team. The goal of care coordination is to assist in managing care, cost, and outcomes across the continuum of patient care as it relates to acute inpatient stay and post-acute facility stay. The Utilization Review RN Coordinates continuing care/outside services for value based risk members (HMO members) in collaboration with the hospital and primary care physician. The Utilization Review RN is responsible to repatriate stable members from nonmember facilities in the emergency department and inpatient setting. This role monitors the patients in Skilled Nursing Facilities and out of network admissions using InterQual and makes assessments regarding appropriate lengths of stay. The process also involves screening for appropriateness of care and talking to the outside physicians to establish stability to and appropriateness of transfer. The Utilization Review RN coordinates and promotes an appropriate post-hospitalization treatment plan and evaluates effectiveness. The position possesses proficient knowledge of evidenced based criteria such as Interqual to review for appropriate care. The implementation of sound clinical, fiscal, and operational strategies is critical to the continued delivery of quality services. Care coordination principles provide an opportunity to balance care with cost. The Utilization Review RN interacts with multiple disciplines to assure high quality, cost efficient care utilizing available resources for Dignity Health members.

Qualifications

Minimum

  • Graduate of an accredited school of nursing.
  • California RN license.
  • Valid State of California driver's license with no restrictions and proof of insurance.
  • Understanding of assessment tools such as InterQual and DRG's; skilled at interviewing techniques; broad knowledge of medical/surgical conditions in all age groups.
  • Percentage Travel Required/Frequency: 50%
  • Minimum 5 years acute care/sub-acute care experience including discharge planning, case management, and/or utilization management.
  • Direct experience working with physicians required.
  • Ca Driver License; CPR; Registered Nurse.
  • Direct experience working with Managed Care and Medicare/Medicaid Regulations necessary.
  • Competent in a variety of computer programs including Microsoft Office suite of products.
  • Strong verbal, written, and interpersonal skills.

Preferred

  • Bachelor Degree in Nursing or other clinical advanced Degree.

  • Clinical training in an acute care or clinic environment.

  • Preferred seven years of acute/sub-acute care experience in combination of utilization management, case management and discharge planning.

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