Utilization Review RN

Dignity Health, one of the nation’s largest health care systems, is a 22-state network of more than 9,000 physicians, 63,000 employees, and 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.

This position is responsible for improving care management coordination between hospital staff and affiliated medical groups and IPA’s by using advanced problem-solving skills, consultation, communication, personal education, and research. This position is also responsible for providing oversight for out-of-network (OON) cases that are capitated to the Dignity Health hospitals (as well as participation in In-Network Utilization management). in the GSSJSA and to provide support to the Director, Clinical Partnerships related to managing capitated business. This position works with affiliated Medical Groups and IPA’s to meet appropriate quality, patient satisfaction, and utilization objectives in a manner consistent with the Mission and Philosophy of Dignity Health.

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Minimum:

• California RN license
• Bachelors in Nursing, Business or equivalent or a combination of knowledge and experience that adequately prepares the individual to competently perform the job.
• Five (5) years experience in utilization review and discharge planning, case management and managed care.

Other qualifications:

• Knowledge of the reimbursement under Medicare, MediCal and private insurance, capitation including Medical group/physician implication.
• Case management of capitated at-risk patients.
• Excellent interpersonal skills to effectively build relationships within and outside the organization
• Understanding of:
  JCAHO and State and Federal Regulations
  Coding, documentation, DRG’s
  Case Management models and standards.
  Nursing theory and practice standards.
  Research models.

We prefer candidates with:

Certification in Case Management