Utilization Management Coordinator RN II - Case Management

St. Joseph Health Santa Rosa , CA 95402

Posted 2 months ago

We are looking for a Utilization Management Coordinator RN II for the Case Management Department at Santa Rosa Memorial Hospital. Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

Location: Santa Rosa, CA

Work Schedule: Part Time

  • 64 Biweekly Hours

Shift: 8-hour, Days

Job Summary:

The Utilization Management Coordinator, in collaboration with other Care Management staff, medical staff, ancillary departments, nursing and all appropriate members of the healthcare team will use professional clinical skills to evaluate opportunities to optimize clinical resource management, utilization of services, and proactively participate in activities to improve revenue cycle management, length of stay and resource utilization. The role of the Utilization Management Coordinator will include, but is not limited to; coordinating and monitoring the provision of care processes to optimize quality of care, patient satisfaction, utilization, cost, pre-admission, admission, concurrent, discharge, and retrospective reviews to ensure medical necessity, assertive application of utilization management strategies to avoid potential denials, and to ensure compliance with federal and state regulations.

Essential Functions:

  • Assessment and Medical Necessity Review: Performs pre-admission, admission, concurrent stay, discharge and retrospective reviews based on established criteria and sound clinical knowledge for the purpose of ensuring medical necessity and appropriateness of services provided. Confers with the medical staff and other members of the healthcare team to ensure documentation supports medical necessity and appropriateness of planned treatments and services. Refers all questions of medical necessity to the attending physician, physician advisor, or other appropriate individual. Works proactively to avoid potential denials in collaboration with other members of the healthcare team, including the physician. Enters authorization and charge entry information as directed. Care Management staff, ancillary staff and nursing. Completes the denial process and provides denial letters to patients as necessary. Works directly with third party payers to provide medical necessity information, ensure timely follow up and collaboration with the medical staff and physician advisors to complete peer to peer discussions in order to avoid potential denials.

  • Monitoring and Evaluation: Identifies opportunities for improving clinical resource management and initiates activities to implement the opportunities. Assists the physician advisor in collecting and trending data (including avoidable day information) for education to members of the health care team. Identifies and analyzes variances from expected outcomes and actively works towards resolution. Participates in Revenue Cycle and Utilization Management activities and meetings as requested. Assertively monitors the treatment plan and progress for quality, timeliness, and effectiveness of services provided, to ensure they are appropriate, cost effective and in order to maximize patient outcomes.

  • Communication: Fosters cordial, positive and professional interpersonal relationships with patients, family members, and physicians, members of the healthcare team, insurance companies, community agencies and peers. Develops high level negotiating skill to effectively work with all members of the healthcare team in order to maximize utilization, quality, and service. Provides information via the appropriate method to payers within designated time frames. Acts as a proactive member of the multidisciplinary discharge planning team to ensure safe and appropriate discharges from acute care services. Identifies administrative issues that may affect reimbursement or increased length of stay (insufficient medical record documentation, lack of timely test or treatment, etc.), and communicates findings to the appropriate department or individual to ensure appropriate coverage and reimbursement.

  • Education: Educates medical staff as appropriate regarding observation versus inpatient status, medical necessity and required medical record documentation. Possesses a working knowledge of financial terms, i.e. PPO, HMO, and patient requirements/expectations. Maintains current knowledge of JCAHO guidelines, Utilization Management Plan, and DRG and reimbursement with expected length of stay. Maintains a high skill level in use of medical screening tools (Milliman and Interqual) and is a resource to others in the use of the tools.

  • Quality Management: Contributes to department and hospital and hospital Quality and Improvement initiatives. Facilitates audits and appeals as required. Promotes the identification and prevention of hospital acquired conditions by notifying appropriate parties when risk or event is identified. Supports the prevention of hospital readmissions and patient satisfaction.

Skills:

  • Demonstrates effective interpersonal and communication skills.

  • Demonstrates tact, diplomacy, negotiation skills, and customer relations.

  • Ability to apply creative problem solving skills.

  • Ability to prioritize assignments and effective time-management skills.

  • Knowledge of diagnosis, expected treatment and discharge planning needs.

  • Knowledge of clinical and psychosocial aspects of patient care.

  • Keep current in clinical screening tools (i.e., Milliman and Interqual guidelines).

  • Ability to present a professional presence and appearance.

  • Detail-oriented, flexible, and committed to patient advocacy.

  • Ability to work interdependently.

  • Demonstrated skills in planning, organizing and managing multiple functions and complex processes.

  • Knowledge of basic computer software programs.

  • Intermediate computer skills.

Minimum Position Qualifications:

Education: Coursework/Training

  • Graduate of accredited school of nursing.

Experience:

  • 3 years of Acute clinical experience as a RN in a healthcare setting.

  • Experience in performing utilization management activities.

License/Certification: Registered Nurse with current California license

Preferred Position Qualifications:

Education: Bachelor's Degree in Nursing

Experience: Experience with appeals and/or audits

Licenses/Certifications:

  • UR

  • URAC

  • CCM certification upon hire or within 1 year

Providence St. Joseph Health (Providence) has worked for decades to improve health and quality of life in California's North Bay region, starting in Sonoma County, where the Sisters of St. Joseph of Orange opened the doors of Santa Rosa Memorial Hospital in 1950. Today, we continue the mission begun by the Sisters to those we serve through an integrated spectrum of primary, urgent, acute, outpatient, palliative care and regional referral services. Sonoma County facilities aligned with Providence include the 278-bed Santa Rosa Memorial Hospital, the region's only Level II trauma center. In addition, the 80-bed Petaluma Valley Hospital and 43-bed Healdsburg Hospital are secular (non-religious) affiliates of Providence. Our services also encompass three Urgent Care centers, Hospice of Petaluma, Memorial Hospice and North County Hospice, the Annadel Medical Group doing business as St. Joseph Health Medical Group, as well as the St. Joseph Home Care Network (post-acute care services). We act as a regional referral hub for outlying hospitals, while also providing outpatient behavioral health care, education to promote health and prevent chronic disease, rehabilitation, oral health care, community benefit programs, and more, all fostering health and quality of life throughout the area.

Providence provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Providence complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Positions specified as "on call/per diem" refers to employment consisting of shifts scheduled on as "as needed basis" to fill in for staff vacancies.

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Utilization Management Coordinator RN II - Case Management

St. Joseph Health