Responsibilities

Position Summary:

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Qualifications

Minimum Requirements:

California RN license.Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used. 

Preferred

Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.At least five (5) years of nursing experience.Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification Proficient in application of clinical guidelines (MCG/InterQual) preferred Knowledge of managed care and payer environment preferred. Overview

Founded by the Sisters of Mercy, Mercy Hospitals have a history of caring for our community that goes back more than 100 years. We provide a broad range of medical and surgical services including minimally invasive and outpatient options. Our family of services includes the area's only inpatient oncology unit, the Orthopedic, Spine, and Hand Center, Family Birth Center, the Lactation Support Center and retail store, and many others. Mercy Hospital Downtown is a 194-bed facility located in downtown Bakersfield. Mercy Hospital Southwest is a 78-bed facility and the only hospital located in the rapidly growing area west of Highway 99. Mercy Hospital is a member of Dignity Health and is a trusted community partner, serving residents of Bakersfield and Kern County with quality, compassionate care since 1910. Learn more here at https://www.dignityhealth.org/central-california/locations/mercy-bakersfield.
#bakersfieldRN

One Community. One Mission. One California