Utilization Review RN II, Care Coordination, Full-Time, Days

MarinHealth is an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, and a new state-of-the-art hospital, MarinHealth comprises MarinHealth Medical Center (a 327-bed hospital in Greenbrae) and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties.

About the role

The Utilization Review Nurse is responsible for completion of admission, concurrent, and retrospective reviews for designated health plans, applying standardized criteria and concurrent documentation. The UR nurse assesses for clinical stability and coordinates transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The role includes initial RAC review prior to submission to the Physician Advisor and appealing medical necessity denials. The UR nurse reviews denials from Patient Financial Services to determine if medical records contain sufficient medical necessity documentation before a written appeal and escalates cases to the Medical Director as necessary.

Responsibilities

• Complete admission, concurrent, and retrospective reviews for designated health plans using standardized criteria.
• Assess clinical stability and coordinate patient transfers back to Marin General when admitted to non-contracted hospitals.
• Perform initial RAC reviews and submit to Physician Advisor.
• Appeal medical necessity denials.
• Review denials from Patient Financial Services to ensure medical records contain sufficient medical necessity documentation before written appeals.
• Escalate cases to the Medical Director to ensure appropriate and effective patient care.

Requirements

• Bachelor of Science degree in Nursing preferred.
• Three (3) or more years of experience in an acute patient care setting, preferably in medical/surgical or critical care.
• Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred.
• Experience applying evidence-based criteria related to utilization management.
• Experience using case management software.
• Registered Nurse license required at hire.
• Basic Life Support certification required at hire.

Skills

• Excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and negotiation skills.
• Ability to read, write, and follow English verbal and written instructions.
• Ability to work independently with minimal direction, anticipate workflow, and prioritize responsibilities.
• Strong attention to detail and accuracy.
• Ability to work in a high-volume caseload environment and manage rapidly changing priorities.
• Demonstrated ability to collaborate constructively with a broad spectrum of healthcare professionals.
• Assertive and creative problem-solving, system planning, and management skills.
• Proficient computer skills, including Electronic Health Record and Microsoft Office Suite.

Benefits

• Measles, mumps, varicella, and annual influenza immunizations required (medical or religious exemptions considered).
• COVID-19 vaccination/booster strongly recommended.

Pay

Compensation range: $66.03 - $99.04 per hour.

Schedule

• 10-hour shifts (days).
• Scheduled weekly hours: 40.