Health System Nurse Case Manager I/II - RUHS Medical Center - Utilization Review/Case Management

Health System Nurse Case Manager

The County of Riverside - Riverside University Health System-Medical Center is seeking highly skilled and experienced Registered Nurses to join their team as a Health System Nurse Case Manager with the UR Case Management Department. Work Schedule: Six (6) 12-hour shifts, 7:00 PM-7:30 AM, and one (1) 8-hour shift, 11:00 PM-7:30 AM. The level at which the position will be filled is at the discretion of the department. Salary Range: Health System Nurse Case Manager I: - $52.3749 - $81.0634 Health System Nurse Case Manager II: $57.3800 - $86.4850 Meet the Team! Founded in 1893, Riverside University Health System Medical Center has grown into a cornerstone of healthcare excellence and medical education in the region. Our highly skilled healthcare professionals and dedicated support staff are committed to delivering exceptional, state-of-the-art care to the diverse populations of Riverside County. Located in Moreno Valley, our 439-bed Medical Center is home to a Level I Trauma Center, a Level II Pediatric Trauma Center, and the county's only Pediatric Intensive Care Unit (PICU). If you're passionate about making a meaningful difference and helping others, RUHS Medical Center is the place for you!

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Examples Of Essential Duties

Within the full scope of the Nursing Practice Act, plan, implement, coordinate, monitor, and evaluate medical services; provide nursing case management, discharge planning and utilization review services to patients; act as department resource for medical inquiries, claim file reviews and utilization review.

Coordinate and monitor patients through the hospitalization process utilizing physicians, nurses, other healthcare providers, and third-party payors to maintain quality care and fiscal responsibility; monitor completion of healthcare services to avoid delays in care and discharge; facilitate third party reimbursement approval and/or authorization.

Provide and coordinate community-based medical post-discharge activities for patients provide early medical management intervention for new patient illness/disease, consulting on medical only files and utilization review on all requests for medical treatment; review the post-hospital care plan with the patient/family; follow plan through to discharge.

Evaluate healthcare services of requesting physicians based on the appropriateness of the service and the level of care at which service would be delivered; act as a neutral advocate for patients; act as a resource to physicians for adequate medical record documentation, appropriateness of facility services as they relate to diagnoses, and options for post-discharge care.

Perform utilization review in concert with the utilization review physician to approve, delay, modify, or deny treatment.

Perform medical reviews on patient services claims and provide recommendations, which are preemptive and focused on moving the patient along the healing continuum.

Apply clinical expertise as a resource to case management staff, physicians, nurses, and other healthcare providers to identify the best results while coordinating the appropriate resource utilization; identify and manage patient problems to eliminate duplication and fragmentation of healthcare services.

Counsel and advise patients regarding proper healthcare methods.

Assist in the development of policies and procedures, standards of care and practice, and in the monitoring of those standards to ensure regulatory compliance, as required by the Joint Commission, Centers for Medicare and Medicaid Services, and the State of California Department of Health Care Services.

Prepare and maintain concise, complete records and reports, including post-discharge documentation.

Promote collaboration among hospital interdisciplinary departments, programs, and physicians; represent the Case Management and Utilization Review Department when needed in hospital committee meetings.

Provide orientation and training to new staff; identify staff training needs.

Participate in quality assurance and performance improvement reviews.

May testify in court as to the client's mental and physical condition.

Minimum Qualifications

Health System Nurse Case Manager I: Education: Successful completion of the coursework required to obtain a valid license to practice as a Registered Nurse in the State of California. Experience: Three years of full-time experience as a Registered Nurse in an acute care facility, mental health facility or community health agency with references and evaluations to show appropriate skill level. Additional qualifying experience as a full-time Licensed Vocational Nurse (LVN) may substitute for the required Registered Nurse experience up to three years on the basis of two years of full-time experience as an LVN equaling one year of full-time Registered Nurse experience. Licensed Vocational Nurse experience must be in an acute care setting within a hospital. One year of experience in Case Management and/or Utilization Review is preferred. (A bachelor's degree from an accredited college or university in nursing may substitute for one year of the required experience.)

Health System Nurse Case Manager II: Option I: Education: Successful completion of the coursework required to obtain a valid license to practice as a Registered Nurse in the State of California. Experience: Four years of full-time experience as a Registered Nurse in a managed care, acute care facility, mental health facility, or community health agency setting that includes a minimum of one year of experience in Case Management and Utilization Review. Option II: Education: Graduation from an accredited college or university with a bachelor's degree in nursing. Experience: Three years of full-time experience as a Registered Nurse in a managed care, acute care facility, mental health facility, or community health agency setting that included experience in Case Management and Utilization Review. Option III: Education: Graduation from an accredited college or university with a master's degree in nursing. Experience: Two years of full-time experience as a Registered Nurse in a managed care, acute care facility, mental health facility, or community health agency setting that included experience in Case Management and Utilization Review. All Options: Knowledge of: Case management and utilization review principles and practices; payor source documentation requirements and governmental regulations affecting reimbursement, managed care, and healthcare issues and standards; application of the nursing process; full range of Registered Nurse duties and responsibilities; community resources available to provide patient care and follow-up; federal, state and local laws and regulations governing professional aspects of nursing; principles and methods of supervision and training; problem solving techniques. Ability to: Plan, organize, supervise, and evaluate nursing services on specific unit(s); communicate effectively; positively manage change and conflict; interpret licensure and accreditation standards; analyze and draft department policies and procedures; apply productive problem-solving skills; write clear and concise reports; perform Registered Nurse or public health nurse responsibilities according to the State of California Nursing Practice Act; implement the nursing process. Other Requirements for Level I and II: License: Must maintain a current, valid license to practice as a Registered Nurse in the State of California. Must possess a valid Basic Life Support (BLS) certification issued by the American Heart Association for professional healthcare providers. Additional Requirement for Health System Nurse Case Manager II: Certificate: Must maintain a current and valid Case Manager Certificate.