Energy Jobline
Utilization Review RN (Hybrid)
Energy Jobline, San Francisco, California, United States, 94199
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Utilization Review RN (Hybrid)
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Utilization Review RN (Hybrid)
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Energy Jobline Job DescriptionJob Description
Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required. Job DescriptionJob Description
Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required.
Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly.
Education
Valid RN license in State of California Bachelor's degree in Nursing
Experience
Clinical experience in acute care setting Required Experience with interqual and millimen
Licenses and Certifications
CPR - Cardiac Pulmonary Resuscitation CPR/BLS and CCM - Certified Case Manager CCM and ACMA
Knowledge, Skills, And Abilities
Verbal and written communication skills. Basic computer skills. Diagnostic and problem-solving skills. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations. Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs. Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate. Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care. Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity. Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission. Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team. Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, and formal educational offerings. Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations. Performs other duties as assigned.
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Renewable Energy Power Generation, Engineering Services, and Oil, Gas, and Mining Referrals increase your chances of interviewing at Energy Jobline by 2x Sign in to set job alerts for “Utilization Review Nurse” roles.
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Utilization Review RN (Hybrid)
role at
Energy Jobline 3 weeks ago Be among the first 25 applicants Join to apply for the
Utilization Review RN (Hybrid)
role at
Energy Jobline Job DescriptionJob Description
Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required. Job DescriptionJob Description
Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required.
Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly.
Education
Valid RN license in State of California Bachelor's degree in Nursing
Experience
Clinical experience in acute care setting Required Experience with interqual and millimen
Licenses and Certifications
CPR - Cardiac Pulmonary Resuscitation CPR/BLS and CCM - Certified Case Manager CCM and ACMA
Knowledge, Skills, And Abilities
Verbal and written communication skills. Basic computer skills. Diagnostic and problem-solving skills. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations. Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs. Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate. Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care. Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity. Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission. Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team. Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, and formal educational offerings. Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations. Performs other duties as assigned.
Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Renewable Energy Power Generation, Engineering Services, and Oil, Gas, and Mining Referrals increase your chances of interviewing at Energy Jobline by 2x Sign in to set job alerts for “Utilization Review Nurse” roles.
San Ramon, CA $130,000.00-$160,000.00 4 months ago Registered Nurse - Home Health Case Manager
San Francisco, CA $81,490.00-$167,370.00 3 weeks ago Registered Nurse (Outpatient Surgery Center)
Registered Nurse - Clinical Nurse Educator
San Leandro, CA $98,260.00-$205,260.00 6 months ago Registered Nurse - RN / Clinic (No Specific Specialty) - CLINIC
San Leandro, CA $98,260.00-$205,260.00 7 months ago Alameda, CA $120,000.00-$200,000.00 6 months ago San Francisco, CA $45.00-$60.00 8 months ago Kentfield, CA $2,000.00-$2,700.00 1 week ago Registered Nurse [Experienced Nurses] - DPH (2320)
San Rafael, CA $130,000.00-$160,000.00 1 month ago Registered Nurse Pediatric Clinical Research
Redwood City, CA $130,000.00-$160,000.00 1 week ago Registered Nurse - Home Care (New Grads Accepted)
Registered Nurse (RN) Home Health - Full Time - $5,000 Sign on Bonus (Richmond Area)
Kentfield, CA $74,000.00-$125,000.00 6 months ago San Francisco, CA $126,000.00-$190,000.00 2 months ago Registered Nurse - RN / Post Anesthesia Care Unit - RR
Hayward, CA $120,000.00-$200,000.00 5 months ago Registered Nurse - Home Care (New Grads Accepted)
Registered Nurse (RN) Home Health - Piedmont
Registered Nurse Pediatric Clinical Research
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr