Utilization Review Program Coordinator RN - Case Management
SUMMARY: The Utilization Review Nurse Coordinator is accountable for oversight of the Utilization Management program at Children's Hospital, under the direction of department leadership. Under minimal supervision, the UR Nurse Coordinator reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. The position combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, the coordinator will facilitate the quality of health care delivery in the most cost effective manner. The coordinator will ensure compliance with all regulations related to Utilization Management, will develop quarterly reports for the U.M. Medical Director for presentation at PT&U committee, and will facilitate UM subcommittee meetings.
JOB REQUIREMENTS: This position requires a) Associated Degree in Nursing, 4 year degree in Nursing or related field preferred b) Active CA RN license, c) Minimum 5 years experience in full time acute care nursing role or equivalent, d) pediatric experience and experience and experience in case management and/or utilization review preferred.
Thorough knowledge of pediatrics preferred. Thorough knowledge of regulatory standards related to Utilization Management. Knowledge of private and public payer reimbursement practices and procedures. Proficiency with word processing, spreadsheets and database software. Excellent organizational and communication skills and ability to work with a variety of health care professionals. Ability to work independently. Prefer candidates with knowledge of and experience with Utilization Management regulations and DRG management.
POSITION DETAILS: Full Time, 80 hours per pay period, days
Valley Children’s Healthcare – one of the largest pediatric healthcare networks in the nation – provides Central California’s only high-quality, comprehensive care exclusively for children, from before birth to young adulthood. Our independent, nonprofit network offers highly specialized medical and surgical services to treat conditions ranging from common to the most unusual and complex at our 356-bed children’s hospital as well as through partner hospitals, specialty care centers, satellite practices and primary care services. Our family-centered, pediatric services extend from a leading pediatric cancer and blood diseases center on the West Coast, and our pediatric heart center known for its expertise and pioneering treatments, to our Level IV neonatal intensive care unit (NICU), the highest level referral center between Los Angeles and the Bay Area. Valley Children’s consistently ranks at the top of our peer group for quality patient outcomes, patient satisfaction and nursing excellence. Recognized as a Magnet® designated facility since 2004 and granted the gold-level Beacon Award for Excellence™ in critical care, Valley Children’s neonatal and pediatric intensive care units ac...hieve some of the lowest mortality rates in the country while treating some of the sickest kids. In affiliation with Stanford University School of Medicine, Valley Children’s Pediatric Residency and fellowship programs provide first-class training for the next generation of pediatricians and pediatric surgical and medical specialists. With more than 550 physicians and 3,400 staff, Valley Children’s partners with other providers and organizations throughout our 12-county service area to support delivering the best care to kids closer to home.