Utilization Review Nurse - Case Management - Per Diem - Shift

Kern Medical has been a community cornerstone since its founding in 1867. Today,
we are an acute care teaching center with 222 beds, offering the only advanced
trauma care between Fresno and Los Angeles. Kern Medical offers a range of
primary, specialty, and multi-specialty services including high-risk pregnancy
care, inpatient psychiatric services integrated with county mental health
programs, and a growing network of outpatient clinics providing personalized
patient-centered wellness care. Kern Medical cares for 15,000 inpatients and
125,000 clinic patients a year.

* Per Diem employees supplement department staffing needs, with no guarantee of
minimum hours.
* Must be willing and available to work four (4) shifts per six (6) week
scheduling period.

Position: Utilization Review Nurse - Per Diem

Compensation

The estimated pay for this position is $41.0485 to $64.6800 per hour. This
reflects only a portion of the total compensation package for this position.
Additional compensation may be available for this role through differentials,
incentives, and bonuses.

Definition

Under supervision, to provide and implement a hospital utilization review and
discharge planning program; and to do related work as required.

Distinguishing Characteristics

Positions in this classification are assigned to the Utilization Review division
of Kern Medical Center. Incumbents perform clinically oriented medical chart
reviews and other administrative tasks to meet the requirements of the medical
center's utilization review plan, state and federal regulations, insurance
company requirements for reimbursement and facility accreditation standards. The
Utilization Review Nurse classification ranges from less experienced nurses, who
will perform administrative tasks concerning Utilization Review and Discharge
planning activities, to experienced nurses who will apply full working knowledge
of applicable regulations and to develop knowledge of outside agencies and
services to develop appropriate discharge plans.

Essential Functions

* Obtains and evaluates medical records for in-patient admissions to determine
if required documentation is present.
* Obtains appropriate records as required by payor agencies and initiates
Physician Advisories as necessary for unwarranted admissions.
* Conducts on-going reviews and discusses care changes with attending
physicians and others.
* Formulates and documents discharge plans.
* Provides on-going consultation and coordination with multiple services within
the hospital to ensure efficient use of hospital resources
* Identifies pay source problems and provides intervention for appropriate
referrals
* Coordinates with admitting office to avoid inappropriate admissions.
* Coordinates with clinic areas in scheduling specialized tests with other
health care providers, assessing pay source and authorizing payment under
Medically Indigent Adult program as necessary.
* Reviews and approves surgery schedule to ensure elective procedures are
authorized.
* Coordinates with correctional facilities to determine appropriate use of
elective procedures, durable medical goods and other services.
* Answer questions from providers regarding reimbursement, prior authorization
and other documentation requirements.
* Learns the documentation requirements of payor sources to maximize
reimbursement to the hospital
* Initiates and completes Disease Related Groups (DRG's) for Medicare payment;
answers questions from providers regarding reimbursement, prior authorization
and other documentation requirements.
* Teaches providers the documentation requirements of payor sources to maximize
reimbursement to the hospital.
* May assist in training of other Utilization Review Nurses.
* Keeps informed of patient disease processes and treatment modalities.

Other Functions

* Performs other job related duties as required.

Employment Standards

Possession of a valid license as a Registered Nurse in the State of California

AND

Two (2) years of experience or its equivalent as a registered nurse in an acute
care hospital, at least one of which was on a medical/surgical ward or unit.

OR

Possession of a valid license as a Registered Nurse in the State of California
and two (2) years of experience as a Case Manager in an alternate medical
setting such as a clinic or physician’s office performing utilization or
discharge planning.

Incumbents may be required to possess and maintain specific certificates
competency based on unit specific requirements as a condition of employment.

Appointees not possessing the American Heart Association Provider Basic Life
Support (BLS) card at time of hire must successfully complete appropriate
training and qualify for the RQI Provider certification within 60 days of
employment. As a continued condition of employment, employee must maintain RQI
Provider certification and competency.

Knowledge of

Payor source documentation requirements and governmental regulations affecting
reimbursement; knowledge of acute care nursing principles, methods and commonly
used procedures; knowledge of common patient disease processes and the usual
methods for treating them; knowledge of medical terminology, hospital routine
and commonly used equipment; knowledge of acute hospital organization and the
interrelationships of various clinical and diagnostic services;

Ability to

Effectively evaluate the medical records of hospital admissions regarding
continuing stay necessity, appropriateness of setting, delivered care, use of
ancillary services and discharge plans; ability to assess and judge the clinical
performance of physicians and other health professionals; ability to communicate
documentation needs in an effective and tactful manner that promotes
cooperation; ability to gather and analyze data and prepare reports and
recommendations based thereon; ability to get along with physicians, other
health providers, outside payor sources and the general public.

Supplemental

A background check may be conducted for this classification.

All Kern County employees are designated "Disaster Service Workers" through
state and local laws (CA Government Code Sec.3100-3109 and Ordinance Code Title
2-Administration, Ch. 2.66 Emergency Services). As Disaster Service Workers, all
County employees are expected to remain at work, or to report for work as soon
as practicable, following a significant emergency or disaster.

If position responsibilities require driving a personal vehicle, then possession
of a current valid California Driver’s License and adherence to the Kern County
Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is
required.

If position responsibilities require driving a vehicle owned, leased or rented
by Kern Medical, then possession of a current valid California Driver’s license,
a signed authorization for Release of Drivers Record Information and adherence
to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy
(ENG-EC-119) is required.