Organization:
SHSO-Sutter Health System Office-Valley

Position Overview:
This position facilitates utilization management (UM) processes to support that the right care is provided at the right place and at the right time. To accomplish these goals, he/she applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the Facility Acute Care Manager (CM). This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team, patient, family and others as necessary.

Job Description:

EDUCATION:

• Graduate of an accredited school of nursing

CERTIFICATION & LICENSURE:

• RN-Registered Nurse of California Upon Hire

PREFERRED EXPERIENCE AS TYPICALLY ACQUIRED IN:

• 2 years recent relevant experience.

SKILLS AND KNOWLEDGE:

• Demonstrates basic knowledge of the role of UM, Care Transition and/or CM for patients within an acute hospital and/or ED setting and across the continuum of care. This will be assessed during the interview process and the candidates narrative answers to case scenarios.
• Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, all value-based reimbursement models, and alternative payment systems preferred.
• Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC.
• A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements.
• Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
• Demonstrates ability to efficiently and independently manage own time and tasks with minimal supervision.
• General understanding of coding and DRG assignment process preferred.
• Excellent verbal and written communication skills required.
• Must be able to communicate effectively with a wide variety of personalities and departments, including members of the medical staff.
• Ability to read, write, hear, and communicate verbally in English to the degree required to perform the job.
• Willingness to act and dress in a professional manner at all times.
• Proficient in using a computer to accurately enter and extract data, send and receive email, calendar appointments, and use task lists associated with a a variety of computer software programs.
• Proficient in the use and application of evidence-based level of care and medical necessity criteria such as InterQual and/or MCG.
• Must be able to meet accuracy and productivity requirements by the organization standards.
• Maintain proficiency in conducting utilization reviews using MCG/InterQual by keeping up with practices and technology, participating in all training and education requirements, and certification or accreditation as applicable.
• Ability to use Microsoft Office Suite products (Outlook, Word, Excel, Power Point) preferred.

Job Shift:
Days

Schedule:
Full Time

Shift Hours:
8

Days of the Week:
Monday - Friday

Weekend Requirements:
Once a Month

Benefits:
Yes

Unions:
No

Position Status:
Non-Exempt

Weekly Hours:
40

Employee Status:
Regular

Pay Range is $82.48 to $115.46 / hour

The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate's experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health's comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.