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RN Utilization Management Nurse - Inpatient - CMC Utilization Management - Full Time - 8 Hour - Days

John Muir Health
United States, California, Concord
Jun 14, 2025
Job Description:The role of the inpatient utilization review (UR) registered nurse (RN) is to provide patient advocacy through appropriate utilization of resources. The UR RN manages inpatient cases at John Muir Concord and/or Walnut Creek Medical Centers to assure that medical care is medically necessary by conducting reviews prospectively, concurrently and retrospectively for appropriateness of admission, level of care and determines appropriate length of stay. In conjunction with the Medical Director/designee, attending physicians, and inpatient case management team, the UR RN is the overall planner of utilization efforts to efficiently manage care from admission to discharge. He/she communicates with payers requesting clinical and psychosocial information to assure appropriate reimbursement and provides support in denial and authorization research, patient eligibility research and documentation of certified days in medical systems. The inpatient UR RN participates in quality improvement activities by identifying opportunities for improvement in areas such as, clinical outcomes, utilization of resources and concurrent data collection. He/she reviews utilization patterns, identifies trends and problem areas, reports and investigates unusual occurrences, and assists in collecting and assimilating clinical data to enhance the quality of services. The inpatient UR RN is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor of Science Accredited School of Nursing Required Experience: 1 year Nursing - Utilization Review Required 2 years Case Management Preferred 3 years Nursing Medical/Surgical or Critical Care Nursing Preferred Additional Experience: Previous experience in the use of software systems for inpatient documentation (i.e. EPIC) and inpatient clinical review criteria (i.e. InterQual,) required. Certifications/Licensures: RN Registered Nursing - California Board of Registered Nursing - Required Skills: Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytic skills. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working knowledge of common diagnoses, procedures and diagnostic codes. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. A high degree of self-directed organizational skills, ability to set priorities, manage multiple demands and the ability to complete tasks under strict time lines is required. Ability to work independently and as a part of a multidisciplinary team. Basic computer and typing skills are required. Able to work in a variety of computer programs, including EPIC, InterQual, Allscripts, and Microsoft Outlook. Work shift: weekends required Work Shift:08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $88.03 - $118.84 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word 'exempt' on it. Scheduled Weekly Hours:40