Resolves, audits, and processes claims for clinically related issues to ensure accuracy of claims payment, supporting the Claims Administration Department. Maintains contact with community hospitals and providers, reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues... [+] More

Resolves, audits, and processes claims for clinically related issues to ensure accuracy of claims payment, supporting the Claims Administration Department. Maintains contact with community hospitals and providers, reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues adjustments as warranted. Typically requires licensure as a Registered Nurse and at least one year of experience in utilization review or a managed care setting.

Screens, audits, and processes claims of specific criteria for appropriate payment. Establishes effective ongoing relationships with community hospitals and providers. Participates in educational, provider relations, and contracting meetings with providers to address medical claims payment issues. Visits the providers as necessary to compare billed charges to the medical record. Provides support to the Accounting Department in determining financial liability for out-of-plan medical services. Performs special projects, reconciliations, research, and analysis relating to the utilization and cost of medical services. Works closely with various departments to coordinate the flow of information involving payment of medical bills and analyses of financial liability. Ensures compliance with contractual obligations on claims payments. Documents findings and writes follow-up reports. Recommends and implements innovative strategies to retain members, contain medical costs, and improve efficiency. [-] Less

Coordinates and supervises all phases of Utilization Review and Social Services. Plans and directs the operational activities of the Utilization Review and Social Services Departments, assuming responsibilities for quality and productivity of utilization review and discharge planning.

Coordinates, facilitates, and integrates... [+] More

Coordinates and supervises all phases of Utilization Review and Social Services. Plans and directs the operational activities of the Utilization Review and Social Services Departments, assuming responsibilities for quality and productivity of utilization review and discharge planning.

Coordinates, facilitates, and integrates high quality, cost-effective care delivered to individuals or groups of patients across an episode of illness or throughout the continuum of care. Assesses, plans, intervenes, and evaluates clinical outcomes. Performs concurrent review of patients' medical records for medical necessity, appropriateness of setting, assessment of the quality of medical care, and the tracking/trending of these activities. Directs the patient complaint and quality management program. Monitors utilization activities and tracks and reports data. Maintains relationships with physicians, department heads, administrators, and clinical coordinators to support intra-departmental goals. Supervises staff. [-] Less

Manages the utilization review function to ensure accurate and timely prior authorization of designated healthcare services, concurrent review, and retrospective review activity. Performs regular data analysis of hospital census, authorization information and medical cost reports to identify variances and root... [+] More

Manages the utilization review function to ensure accurate and timely prior authorization of designated healthcare services, concurrent review, and retrospective review activity. Performs regular data analysis of hospital census, authorization information and medical cost reports to identify variances and root causes so that areas of focus may be identified and resources may be appropriately deployed.

Manages the utilization review function to ensure accurate and timely prior authorization of designated healthcare services, concurrent review, and retrospective review activity. Manages a department responsible for the determination of medical necessity and appropriateness of care based on predetermined criteria and/or guidelines. Plans, organizes, implements and evaluates departmental outcomes. Performs regular data analysis of hospital census, authorization information and medical cost reports to identify variances and root causes so that areas of focus may be identified and resources may be appropriately deployed. Prepares and manages the departmental budget. Hires, develops and motivates a qualified utilization review department staff. Ensures that benefits and policies are properly interpreted and that care is rendered in the most appropriate site of service with a focus on quality care and cost efficient outcomes. Assures timely response to provider requests for services per department standards. Conducts regular clinical reviews for utilization management activities, based on guidelines and standards for patients in a variety of settings. A Registered Nurse with clinical and managed care experience is typically required for this position. [-] Less

Serves as an information coordinator for the hospital-wide quality assurance program. Directs development of monitors, including generic screens, to assess the quality of care provided to patients.

Supports the overall quality assurance reporting system to assure that information is being channeled... [+] More

Serves as an information coordinator for the hospital-wide quality assurance program. Directs development of monitors, including generic screens, to assess the quality of care provided to patients.

Supports the overall quality assurance reporting system to assure that information is being channeled to appropriate oversight committees. Provides consultation to health care providers as needed to facilitate problem-focused studies of patient care, which may include advice and support for clinical/legal implications of quality issues. May assume Risk Management responsibilities. May supervise several employees. [-] Less

Treats and provides nursing care to Critical Care Unit patients in hospital or similar health care facility. Readies equipment and aids physician during treatments and examinations of patients. Administers prescribed medications and treatments in accordance with approved nursing techniques. Observes... [+] More

Treats and provides nursing care to Critical Care Unit patients in hospital or similar health care facility. Readies equipment and aids physician during treatments and examinations of patients. Administers prescribed medications and treatments in accordance with approved nursing techniques. Observes patient, records significant conditions and reactions, and notifies supervisor or physician of patient's condition and reaction to drugs, treatments, and significant incidents. Requires RN license.

Takes temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and assess condition of patient. Lends psychological and emotional support. Answers questions and concerns and provides information to patients and their family members regarding patients' care and treatment. [-] Less

Manages the care of neonatal patients resulting from the childbearing process that requires moderate to complex assessments, interventions, and level of nursing vigilance. Provides tertiary and quaternary care to premature infants and newborns. Works with critically ill neonates with life-threatening... [+] More

Manages the care of neonatal patients resulting from the childbearing process that requires moderate to complex assessments, interventions, and level of nursing vigilance. Provides tertiary and quaternary care to premature infants and newborns. Works with critically ill neonates with life-threatening medical or surgical conditions, such as respiratory distress, birth depression, congenital anomalies, infection and surgical conditions. Provides direct and indirect patient care in collaboration with Neonatologist. Typically requires licensure as a Registered Nurse with ICU or neonatal experience. Resuscitation credentials are typically required.

Conducts an individualized patient assessment, prioritizing the data collection based on the neonatal patient's immediate condition or needs within timeframe specified by the facility's policies, procedures, or protocols. Conducts ongoing assessments as determined by the neonatal patient's condition and the facility's policies, procedures, or protocols and reprioritizes care accordingly. Develops plan of care that is individualized for the neonatal patient reflecting collaboration with other members of the healthcare team. Performs therapeutic nursing interventions as established by individualized plan of care for the neonatal patient and family. Provides individualized patient/family education customized to the neonatal patient and family. Documents patient assessment findings, physical/psychosocial responses to nursing intervention, and progress towards problem resolution. Initiates emergency resuscitative measures according to neonatal resuscitation protocols. Maintains confidentiality in matters related to patient, family, and staff. Reports patient condition to appropriate personnel during each shift. Maintains established policies and procedures, safety, and infection control standards. [-] Less

Treats and provides professional nursing care to patients in the obstetrical and gynecological departments. Administers prescribed medications and total patient care in the labor room, delivery room, postpartum unit, and nursery. Requires RN license.

Maintains patients' medical records. Aids physician during treatments, examinations, and surgical procedures. Evaluates, plans, and documents the delivery room nursing process as needed.

Treats and provides professional nursing care to patients in the obstetrical and gynecological departments. Administers prescribed medications and total patient care in the labor room, delivery room, postpartum unit, and nursery. Requires RN license.

Maintains patients' medical records. Aids physician during treatments, examinations, and surgical procedures. Evaluates, plans, and documents the delivery room nursing process as needed.

Treats and provides professional nursing care to patients in the obstetrical and gynecological departments. Administers prescribed medications and total patient care in the labor room, delivery room, postpartum unit, and nursery. Requires RN license.

Maintains patients' medical records. Aids physician during treatments, examinations, and surgical procedures. Evaluates, plans, and documents the delivery room nursing process as needed.

Plans, organizes, and supervises, under general direction, the activities of the Utilization Review unit of a hospital. Ensures compliance with reimbursement rules of third-party payers. Performs the more complex utilization review work. Monitors and ensures hospital compliance with Medic-Cal, Medicare,... [+] More

Plans, organizes, and supervises, under general direction, the activities of the Utilization Review unit of a hospital. Ensures compliance with reimbursement rules of third-party payers. Performs the more complex utilization review work. Monitors and ensures hospital compliance with Medic-Cal, Medicare, and insurance reimbursement policies, the maintenance of patient care quality, and the maximizing of reimbursements for services provided. Reports to the Hospital Quality Assurance Manager.

Plans, organizes, and supervises the staff of the Utilization Review unit. Reviews and analyzes government and accrediting agency standards governing admissions, treatment, and continued stay of patients. Develops policies and procedures for adherence to governmental and accrediting agency standards. Coordinates the work of the Utilization Review staff with medical staff to ensure appropriate and timely patient care action and to maximize reimbursement. Analyzes individual patient records to determine appropriateness of admission. Reviews patient treatment plans for adherence to established criteria and standards. Refers cases that fail to meet criteria to the Patient Care Review Committee for review and course of action. Conducts studies and prepares reports for the review committee, medical staff, and administration. Serves as review committee liaison with other committees to coordinate formulation of policy and procedures. Explains procedures and documentation requirements to medical staff, managers, and other hospital personnel. Interviews, selects, trains, and evaluates Utilization Review staff. [-] Less