Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process.
Essential Functions:
- Conducts utilization review for in-house patients and/or members who have been admitted to contracted facilities.
- Conducts clinical reviews based on established treatment criteria.
- Reviews utilization patterns and identifies trends and problems areas for special studies.
- Assists other health care providers in the discharge planning process and triaging on alternative unit of care.
- Assists in collecting and assimilating clinical data to enhance the quality of services.
- Generates quality improvement results.
- Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria.
- Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise.
- Interviews patients/caregivers regarding care after hospitalization.
- Counsels on Medicare and health care plan coverage.
- Coordinates referrals to appropriate agencies/facilities.
Qualifications:
Basic Qualifications:
- Previous experience in an inpatient setting (usually two (2) years).
- Previous experience utilization experience required (usually one (1) year).
- Bachelors degree, or equivalent experience, in nursing or a health related field required.
- Master's degree preferred.
- Graduate of accredited school of nursing.
- Current California RN license.
- Clinical expert in area of review preferred.
- Demonstrated knowledge of diagnostic codes.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.