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.
SUPERVISION RECEIVED AND EXERCISED
Receives general supervision from the Deputy Director, Medical Care Services.
EXAMPLES OF ESSENTIAL DUTIES
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, SKILLS, AND ABILITIES
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.
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.