Summary

SUMMARY: The System Utilization Management [SUM] Utilization Review RN is responsible for ensuring the appropriate use of healthcare resources while maintaining high- standards of patient care. This role involves evaluating medical necessity, assessing treatment plans, and collaborating with healthcare providers and payers to ensure compliance with regulations and coverage criteria. The UR RN plays a critical role in optimizing care delivery, reducing avoidable inpatient denials, and improving overall healthcare.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Acts as a liaison between payers, billing, and medical staff by supplying appropriate medical information to determine level of care status.

2. Collaborate with Emergency Department physicians and Hospitalists to ensure accurate patient class placement (e.g., inpatient, observation, outpatient).

3. Expeditiously refer cases to the internal/external Physician Advisor for review of requests that may not meet medical necessity criteria.

4. Review admission orders and documentation to confirm alignment with regulatory requirements and payer guidelines.

5. Review planned admissions to ensure that services are medically necessary, appropriately authorized by the payer, and assigned to the correct level of care.

6. Ensure compliance with federal, state, and organizational regulations, including Medicare and Medicaid guidelines.

7. Stay informed about CMS Conditions of Participation (COP), payer-specific requirements, and industry standards.

8. Maintain accurate documentation of reviews, findings, and actions in the EHR system.

9. Conduct concurrent and admission reviews of patient records to assess medical necessity and adherence to evidence-based guidelines.

10. Collaborate with care coordinators to ensure the delivery of regulatory notices.

11. Submit clinical documentation and coordinate with insurance companies to secure proper authorizations.

12. Access payer portals to seek inpatient authorizations.

13. Identify and address any gaps in documentation that may affect proper classification or reimbursement.

14. Provide real-time feedback and education to clinicians regarding best practices in resource utilization.

15. Maintain continued professional growth and education to meet continuing education requirements.

16. Participate in orientation of fresh staff as requested by the Manager of Utilization Management.

17. Maintains knowledge of current trends and changes in healthcare delivery as it pertains to utilization review (e.g., medical necessity, level of care) by participating in appropriate educational opportunities. (Webinars, conferences, local training, Compass Modules).

MINIMUM QUALIFICATIONS:
Required Education: BSN from an accredited school of nursing

Preferred Education: Master's degree in nursing

Required Experience: Minimum three (3) years of experience in Utilization Management or Case Management AND proficiency in applying InterQual Criteria (95% or higher IRR)

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California

Preferred Licenses/Certifications: Certified Case Manager (CCM) or Accredited Case Manager (ACM)