JOB PURPOSE 

The Utilization Review Nurse is responsible for utilization review, utilization management, and quality assurance activities for assigned services/areas/patients within the Cottage Health System and will champion, engage, manage and monitor proactive communications and interventions by and between relevant stakeholders with regard to utilization review management. The Utilization Review Nurse will work collaboratively and proactively with the medical staff, nursing staff, and other disciplines to support and achieve the goals of the collaborative care process. Additional responsibilities include: maintain a working knowledge of regulations and provider contracts governing coverage of inpatient services (i.e., Medicare, Medi-Cal, Contracted Medical Groups); maintain and model interpersonal skills and productive relationships that allow for and support effective interaction with a wide variety of stakeholders; consistently demonstrate professionalism and compassion with regard to human dignity, preserving and protecting client autonomy and rights and with respect for patient/family values and beliefs. Utilization review activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction, and contribution to an overall value-oriented experience of stakeholders and persons served in a manner compliant with The Joint Commission, HIPAA and Title 9 Regulations (DHCS).

QUALIFICATIONS 

All job qualifications listed indicate the minimum level necessary to perform this job proficiently.

LEVEL OF EDUCATION 

Minimum: Minimum education to allow candidate to achieve California RN license.

Preferred: Bachelor's Degree in Nursing (BSN) 

CERTIFICATIONS, LICENSES, REGISTRATIONS 

Minimum: Current California Registered Nurse license in good standing. 

Preferred: Certification in Case Management. 

TECHNICAL REQUIREMENTS 

Minimum: Ability to use an electronic medical records system and other clinical systems, such as AllSCRIPS, CPOE, and/or SUNRISE. 

Preferred: 

YEARS OF RELATED WORK EXPERIENCE 

Minimum: Minimum of two years direct patient care RN experience in an acute care setting. Other direct patient care RN experience may be considered. 

Preferred: 3 years of experience as a Utilization Review Nurse in an acute care setting.