Concurrent Utilization Management Nurse

General Information

Job Name Concurrent Utilization Management Nurse Department 8750080 - Utilization Management SFMED Position type Full Time Workplace Flexible 1 Day On-Site Primary Location United States Job ID 5916

Description & Requirements

Job Description

JOB SUMMARY

T he Concurrent Utilization Management (UM) Nurse is responsible for completing pre-admission,         initial, concurrent and/or retrospective reviews of inpatient hospitalization services and for the determination of medical appropriateness and medical necessity for a variety of patient cohorts using evidence-based clinical guidelines and/or nationally recognized criteria.  The UM RN will use their clinical findings from their reviews to inform the care team of level of care recommendations, identify continued stay variances, relay and attempt to overcome authorization issues, generate estimated expected dates of discharge, as well as highlight any provider documentation concerns.

Department Description The UCSF Health Utilization Management Department is part of the multidisciplinary team of expert clinicians and staff, who continually strive to provide proactive patient centered access to care and resources along the healthcare continuum. This department evaluates the efficiencies, appropriateness and medical necessity of treatments, services, procedures, and facilities provided to patients on a case-by-case basis using identified evidence-based criteria guidelines. This department works closely with patient?s insurers, compliance, admitting, case management and patient financial services to ensure that the organization is reimbursed for the clinically appropriate care provided to our patients. Qualifications Required qualifications: - A minimum of two years recent Case Management, Utilization Management and/or Utilization Review work experience. Working knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, basic disease processess and basic knowledge of medical records coding standards. Skilled in the operation of computers including strong working knowledge of Microsoft Outlook ®, Microsoft Word ®, and Microsoft Excel ®. Knowledge of billing practices, adequacy of documentation, and ability to conduct research on issues at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to this topic; awareness of licencing and accrediation standards. Solid organizational skills and ability to multi-task with demanding timeframes. Knowledge and experience with MCG and/or InterQual criteria. Advanced interpersonal and communication for written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team and/or external reviewer; prioritization and organize work to meet changing priorities. Ability to use discretion and maintain confidentiality. Possess strong analytical ability required to gather data, use clinical judgement to apply predetermined criteria, or uses independent clinical judgement when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively. Self-directed with the ability to prioritize and adapt to a high-volume changing environment. Independent clinical judgement in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents, and participate in focused reviews, special projects and identify opportunities for improvement. Assertive and creative in problem solving abilities while functioning as an active team member. Strong customer service skills to coordinate service delivery including attention to members/customers, sensitivity to concerns, proactive identification and resolution of issues to promote positive outcomes for members. Ability to type minimum 45 wpm using a QWERTY keyboard. Ability to perform all job responsibilities independently without direct supervision in offsite or onsite work environments while still maintaining expected productivities. Demonstrates ability to take direction from multiple team members across multiple departments. Preferred qualifications: - Master’s degree in healthcare - InterQual Certified Expert or Instructor - MCG Certified Expert or Instructor - National healthcare certification Licenses/Certifications: - Possesses a bachelor’s degree in healthcare or related field. - Current Registered Nurse in the State of California - Completed an InterQual or MCG training course License / Certification Registered Nurse About UCSF The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world’s leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells. Pride Values UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence – also known as https://www.ucsf.edu/about/mission-and-values . In addition to , UCSF is committed to equity – both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available https://diversity.ucsf.edu/ . Join us to find a rewarding career contributing to improving healthcare worldwide. EEO Statement The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

Additional Details

Job Code CASE MGR EX (007870) Assignment Category Career IAP Level Staff Plan (target potential payout of $900, maximum of $1,800) Job Family Care Coordination Campus 1 Various Locations Percentage (%) 100.00 Shift Length 8 hours Shift Type Day Bargaining Unit HX Additional Shift Details Weekends and holidays, as needed