SUMMARY

The Utilization Review RN reviews client health records to ensure proper utilization of treatment resources.

REQUIREMENTS

RESPONSIBILITIES AND DUTIES:

• Coordinates and reviews all medical records, as assigned to caseload.
• Actively participates in Case Management and Treatment Team meetings
• Serves as on-going educator to all departments.
• Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
• Able to work independently and use sound judgment.
• Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
• Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
• Performs other duties as assigned.

EDUCATION & EXPERIENCE REQUIREMENTS:

• Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.
• CA RN License Required
• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

SKILLS & ABILITIES REQUIREMENTS:

• Communication
• Planning & Organizing
• Problem Solving
• Attention to Detail

PHYSICAL REQUIREMENTS:

• Body Positions: Sitting and standing for prolonged periods.

• Body Movements: Arm and hand dexterity.

• Body Senses: Must have command of close and distant sight, color perception and hearing.

• Strength: Ability to lift and move up to 25-pounds.

Working Environment:

• Work in an office, where the climate is controlled.
• OSHA exposure category: I

1. Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
2. Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
3. Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens.  This position would not be required to perform Category I tasks.