Utilization Review Registered Nurse

Incumbents perform professional nursing duties in the care and services to patients and their families in an acute care facility; provide quality control and improvement functions; may coordinate a continuum of care for a selected group of patients from pre-admission through post-discharge; and to do other work as required. May be responsible for oversight, development, implementation, and coordination of special programs, services and education in the mental health care setting. Incumbents in the fourth level of this series perform the advanced level functions while demonstrating exceptional expertise within a specialty area and serve as resource persons in this specialty area to staff. Responsibilities are further expanded to include a full range of complex mental health assessments, medication monitoring, counseling and case management, assignments in training needs assessment, in-service training, problem solving clinical and administrative issues and standardizing related policies and procedures. To serve in the absence of the nurse in charge of the department as needed and to preceptor and mentor staff who have been newly hired to the unit or staff who float to the unit. Incumbents review and analyze government and accrediting agency standards governing admissions, treatment, and continued stay of patients. Ensures hospital compliance with Medi-Cal, Medicare, and insurance reimbursement regulations and polices. Analyzes individual patient records to determine appropriateness of admission; reviews patient treatment plans for adherance to established criteria and standards.
REQUIREMENTS
Knowledge of: Payor source documentation requirements and governmental regulations affecting reimbursement; acute care nursing principles, methods, and commonly used medical procedures; common patient disease processes and the usual methods for treating them; medical terminology, hospital routine, and commonly used equipment; acute care hospital organization and the interrelationship of various clinical and diagnostic services. Ability to: Plan, organize and supervise the work of subordinates; develop policy and procedures within prescribed mandates; provide training and ongoing technical guidance; evaluate the medical records of hospital admissions; make recommendations regarding continued stay necessity, appropriateness of the level of and delivery of care, use of ancillary services, and discharge plans; assess and judge the clinical performance of physicians and other health professionals; communicate documentation needs in a manner that promotes cooperation; gather and analyze data and prepare reports and recommendations; work effectively with physicians, other health providers, outside payor sources, and the general public. Education: National Certification in Nursing or health related field or Bachelor’s Degree in Nursing or health related field. Experience: 6 years of current experience full time as a Registered Nurse with a minimum of two years experience in area of specialty. A Masters Degree will substitute for two years of general experience. License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California. All employment offers are contingent upon successful completion of both a pre-employment physical exam, including a drug/alcohol test, and a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment). Veteran's preference, special accommodation or other employment questions please visit our website at http://www.rc-hr.com