Inpatient Concurrent Review RN

Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California.  Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.  

***This position is hybrid in-clinic/hospital and work from home.

Position Summary:

This position is responsible for monitoring Dignity Health Medical Foundation inpatient admissions and concurrent review for appropriate level of care and medical necessity using InterQual and Medicare criteria. This position will work closely with the hospitalist team Dignity Health Medical Foundation Medical Director’s specialists clinic staff and Inpatient care coordination to communicate all Dignity Health Medical Foundation inpatient needs level of care and medical necessity. This position will also work closely with Dignity Health Medical Foundation clinical staff post-acute staff and hospital care coordination to coordinate the care necessary for successful post hospitalization and transition of care needs across the continuum of healthcare.

Responsibilities may include:
- Concurrently review patient’s records to collect data to carefully understand the needs of the patient by scrutinizing their background history understanding their current needs and arranging for their wellbeing.
- Coordinates with other disciplines to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs.
- Perform concurrent review of emergent/urgent and continued stay requests for appropriate care admission status level of care following guidelines and policies. Approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other.
- Complete medical necessity and level of care concurrent reviews for requested services using clinical judgment and established guidelines. Refer to Medical Directors for review depending on case findings.
- Collaborate with various staff within provider networks hospital teams and Inpatient Care Coordination to establish discharge planning expectations to coordinate transition of care needs.
- Identify and facilitate resolution of system process problems impeding UM functions. Identify collaborate and resolve.
- Facilitate the annual update of InterQual (or other screening tool) software create training tools in collaboration with UM leadership.
- Assist with developing and maintaining efficient and effective documented policies and procedures for non-coverage notifications including Notice of Non-coverage (HINN) and Advance Beneficiary Notice of Noncoverage (ABN) to include compliance monitoring.
- When barriers are identified assists the patient family caregiver care coordination with Utilization management as related to referrals.
- Considers the population served by Dignity Health and area clinical integration programs and leads efforts to optimize utilization management and care coordination across the care continuum in the most cost effect manner.
- Other duties as assigned.

Minimum Qualifications:

- Three (3) years acute care or related experience including experience in case management utilization review or discharge planning.
- Clear and current CA RN license.

Preferred Qualifications:

- Concurrent review prior authorizations for medical determination.
- Bachelors degree preferred.