RN-Case Management (Utilization Review)

Position: RN – Case Manager (Utilization Review)
Location: Bakersfield CA 
Contract Length: 13 Weeks
Shift & Schedule: Day Shift (40 hrs - 8-Hour X 5 Days a week)
Employment Type: Contract On site

Position Summary
We are seeking an experienced RN Case Manager – Utilization Review for a 13-week contract assignment in Bakersfield, CA. The ideal candidate will have strong acute care experience, utilization review expertise, and proficiency with InterQual Guidelines. California RN experience is required. The Utilization Review Nurse II performs comprehensive utilization review and discharge planning activities to ensure appropriate use of hospital resources, compliance with payor requirements, and effective patient care coordination.
 
Responsibilities

• Review and evaluate inpatient admissions to ensure required medical documentation is complete and medically necessary.
• Obtain appropriate records required by payor agencies and initiate Physician Advisories when necessary.
• Perform ongoing utilization reviews and communicate care recommendations with physicians and interdisciplinary teams.
• Develop, coordinate, and document discharge planning activities.
• Collaborate with hospital departments to ensure efficient utilization of healthcare resources.
• Identify reimbursement and payor source issues and coordinate appropriate interventions.
• Coordinate with admitting offices to prevent inappropriate admissions.
• Assist clinic areas with scheduling specialized tests and obtaining necessary authorizations.
• Review and approve surgery schedules to ensure elective procedures are authorized.
• Coordinate care services with correctional facilities and external providers as needed.
• Educate providers regarding reimbursement requirements, prior authorizations, and documentation standards.
• Maintain current knowledge of disease processes, treatment modalities, and regulatory requirements.
• Assist with training and mentoring Utilization Review Nurse I staff when applicable.
• Perform additional related duties as assigned.

Required Qualifications

• Active and unrestricted California Registered Nurse (RN) license
• Current American Heart Association (AHA) BLS Certification
• Minimum 2 years of acute care RN experience
• At least 1 year of medical/surgical unit experience
• Minimum 1 year of utilization review and/or discharge planning experience in an acute care setting
  OR  Minimum 2 years of Case Management experience in a clinic, physician office, or alternate healthcare setting performing utilization review or discharge planning
• Experience using InterQual Guidelines
• Strong knowledge of:  Utilization Review, Discharge Planning, Case Management
• Payor source documentation requirements
• Government reimbursement regulations
• Acute care nursing principles
• Medical terminology and hospital operations

Preferred Qualifications

• Previous California acute care hospital experience preferred
• Strong understanding of reimbursement and authorization processes

Education Requirements

• Highest level of education listed on resume required

Certifications & Licensure

• Active California RN License
• Current AHA BLS Certification