Placer County

To monitor all hospital inpatient admissions and stays for conformance to Medicare standards; to provide case coordination among eligibility, authorization, provider contracts and medical aspects of patient care in all potential Medi-Cal cases; and to ensure effective utilization of medical services and appropriate medical service reimbursement.

Duties may include, but are not limited to, the following:

• Review inpatient admission records to ascertain medical justification for admission; assure that admissions are to the appropriate service and level of care; review patient progress to determine need for continued hospitalization.
• Assist in the coordination of patient transfer from hospital facility to alternate facility as soon as an acute level of care is no longer required.
• Consult with reviewing agencies of fiscal intermediaries including but not limited to Med-Cal, Medicare and private insurance companies regarding reimbursement for medical services.
• Assist with the issuance of cost significant treatment authorizations and regularly review all such authorizations.
• Authorize, with physician concurrence, payment of outside medical care, such as hospitals, nursing homes, physician services and dental services.
• Provide information to medical staff regarding documentation required for reimbursements, program coverage and utilization review activities and processes; work with various medical personnel to interpret utilization review program changes and recommend revisions to operational procedures.
• Assist in the establishment and monitoring of guidelines to evaluate the approval of optional or non-life threatening services.
• Provide case documentation in patient medical records and appropriate administrative records.
• Build and maintain positive working relationships with co-workers, other County employees and the public using principles of good customer service.
• Perform related duties as assigned.

Experience and Training
Any combination of experience and training that would provide the required knowledge and abilities is qualifying. A typical way to obtain the required knowledge and abilities would be:

Experience: Three years of responsible registered nursing experience in a clinical setting; one year in a utilization review capacity is desirable.

Training: Equivalent to the completion of the twelfth grade. Additional specialized training in professional nursing or a related field is desirable.

Required License or Certificate:

• Possession of a valid license as a Registered Nurse issued by the California Board of Registered Nursing.
• May need to possess a valid driver's license as required by the position. Proof of adequate vehicle insurance and medical clearance may also be required.

Knowledge of:

• Practices and principles of nursing care.
• General principles and methods of clinical care and medical treatment, including purpose and expected outcomes.
• Utilization review techniques and practices.
• Laws, regulations, policies and procedures relating to government sponsored medical care and other medical aid/assistance programs.
• Modern office procedures, methods and computer equipment.
• Differing cultural, religious, economic and social groups and their relationships to the delivery and acceptance of health care services.
• Services and functions of other social and health agencies/providers relative to public health nursing.

Ability to:

• On a continuous basis, know and understand all aspects of the job; intermittently analyze procedures, reports and patient charts; identify and interpret technical and numerical information; interpret work assignments; and explain policies and procedures to patients and various providers.
• Intermittently, sit while reading reports, records and patient charts; walk, stand, bend, squat or twist when retrieving or returning files and documents; intermittently twist to reach equipment surrounding desk; perform simple grasping and fine manipulation; use telephone and write or use a keyboard to communicate through written means; and occasionally lift light weight.
• Independently interpret rules and regulations and medical records.
• Prepare and maintain accurate records.
• Interpret medical terminology for non-medical personnel performing admission activities.
• Work with various cultural and ethnic groups in a tactful and effective manner.
• Obtain information through interview; deal fairly and courteously with the public; and handle multiple utilization review cases concurrently; work with interruptions.
• Analyze situations quickly and objectively and to determine proper course of action.
• Use a computer, calculator, typewriter, telephone, facsimile machine, postage meter and photocopy machine.