Description
At NorthBay Health the Clinical Utilization Review Nurse II (URN) is an experienced registered nurse who prospectively and concurrently evaluates appropriateness of inpatient and observation services based on clinical documentation, evidence-based guidelines and insurance benefits, and communicates required clinical information to payers in accordance with contractual and regulatory obligations. The Level II URN serves as a clinical resource to physicians/providers by providing education related to medical necessity, utilization review and payer requirements.
PRIMARY JOB DUTIES
Perform comprehensive admission and continued-stay reviews for inpatient and observation cases using facility-approved criteria and payer rules.
Ensure utilization review documentation is accurate, timely and audit-ready, clearly reflecting clinical facts, criteria application and rationale.
Identify opportunities for alternative levels of care when criteria are not met.
Identify short-stay risk, disputed status and medical necessity concerns and escalate to Physician Advisor or leadership as indicated.
Oversee and ensure the Daily Review Tracker, Ambulatory Surgery list and Observation-to-Inpatient list are consistently maintained, updated and reviewed in a timely manner; validates data integrity, identifies gaps or delays and initiates corrective action as needed.
Prepare concise clinical summaries for peer-to-peer discussions and payer communications.
Monitor and report denial trends, avoidable days and utilization issues within assigned workload for continued process improvement.
Collaborate with revenue cycle on claim issues and appeals.
Analyze population-specific utilization patterns and communicate issues impacting progression of care.
Promote use of evidence-based protocols, pathways and order sets to support high-quality and cost-effective care.
Participate in audits, quality improvement initiatives, shared governance activities and ongoing competency development.
Qualifications
Education:
Graduate of an accredited school of nursing. BSN required.
Licensure:
Current California RN License and Magnet ANCC-recognized Case Management certification (CCM, ACM-NBCM, etc.).
Experience:
Minimum of 5 years of clinical nursing experience including 3 years in utilization review/case management.
Advanced knowledge of Milliman Care Guidelines, Medicare/Medicaid and managed care requirements.
Skills:
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments and performance evaluations.
Sufficient proficiency in speaking, reading and writing the English language necessary to perform the essential functions of this job, especially regarding activities impacting patient or employee safety or security.
Ability to effectively communicate with physicians and co-workers in a manner consistent with a customer service focus and application of positive language principles.
Advanced knowledge of Milliman Care Guidelines and knowledge of local and national coverage determinations.
Comprehensive knowledge of Medicare, Medicaid and Managed Care requirements.
Comprehensive knowledge of health care financial and payer requirements/issues.
Comprehensive knowledge of utilization review, case management, performance improvement, and managed care reimbursement.
Ability to work independently and exercise sound judgment in interactions with physicians and health care team members.
Strong assessment, organizational and problem-solving skills; strong time-management and ability to handle high-volume UR reviews without dropping documentation quality.
Comfort navigating EMRs and UR documentation tools with accurate data entry and audit readiness.
Maintains level of professional certification/s as required.
Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).
Competent computer skills in Cerner, Adobe and Microsoft Office Suite (Excel, Teams, Outlook, PowerPoint and Word)
Interpersonal Skills:
Demonstrates professional and respectful communication.
Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position.
Demonstrates a courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.
Utilizes critical thinking and applies sound clinical judgment and assessment skills for decision making.
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