Dignity Health

Utilization Review RN

Job ID
Employment Type
Full Time
Utilization Review
Hours / Pay Period
Sequoia Physicians Network and Affiliates
Standard Hours
M-F, 8-5


Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service.


Sequoia Physicians Network, a service of Dignity Health Medical Foundation (SPN), is a network of more than 200 leading primary care and specialty providers in San Mateo County. SPN provides the managed care administration for several major HMO insurance plans and is affiliated with Sequoia Hospital, an accredited hospital that has served the community for more than 60 years.


Position Summary:


This position will review medical records, benefit, contractual and other guidelines to determine benefit coverage, medical appropriateness including, access, scope availability, and level of care considerations. Position updates and processes member records. Position assists Member Services Dept, Claim Dept. and Physician and ancillary Providers and Health Plans with issues that require medical interpretation, research or clarification. Position performs audits of various medical records and documentation as needed. Position works closely with Primary Care and Specialist physicians, Medical Director, ancillary providers and case management to coordinate member care. Position performs function of a clinical resource to non-licensed staff. Develops support tools for communication of standards and expectations.


Responsibilities may include:
- Reviews and approves prior authorization requests for medical necessity within NCQA timelines using the predetermined criteria provided by the different plans and UM Committee criteria.
- Responsible for timely and appropriate denial letters that meet standards, coordinating with other team members, printing and distribution of letters.
- Reviews correct CPT, HCPC, ICD-9 codes for each referral.
- Clarifies information and answers prior authorization questions from medical offices and providers.
- Performs audit of prior authorization database to monitor timelines set by NCQA.
- Prepares frequent emergency room usage information for UM management.
- Performs audits of various medical records and documentation and implementation of criteria of various staff.
- Other duties as assigned.


Minimum Qualifications:


- Minimum of five (5) years experience as an RN. Two (2) years experience in a medical insurance environment.
- Clear and current CA RN license
- BS or BA.
- Competent in use of Microsoft Word, Excel, and Windows. Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment. 45wpm and 10 key by touch required.
- Familiar with multiple medical specialty procedures and diagnoses.


Preferred Qualifications:

- Supervisory experience preferred.
- Physician group experience preferred.
- HMO/Managed Care experience preferred.
- Familiarity with an electronic practice management system is preferred.






Keywords:  Utilization management, UM, UR, care coordination, health plan, healthplan, IPA, nurse, registered nurse, RN, non-patient care


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