Job Details

SUMMARY: The Utilization Review Nurse Coordinator is accountable for oversight of the Utilization Management (U.M.) program at Valley Children's Healthcare, under the direction of department leadership. Under minimal supervision, the UR Nurse Coordinator reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. The position combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, the coordinator will facilitate the quality of health care delivery in the most cost effective manner. The coordinator will ensure compliance with all regulations related to Utilization Management, will develop quarterly reports for the U.M. Medical Director for presentation at Pharmacy Therapeutics & Utilization (PT&U) committee, and will facilitate UM subcommittee meetings.

Valley Children’s Healthcare – one of the largest pediatric healthcare networks in the nation – provides Central California’s only high-quality, comprehensive care exclusively for children, from before birth to young adulthood. With more than 670 physicians and 3,500 staff, Valley Children’s delivers high-quality, comprehensive care to more than 1.3 million children in our service area. Our network offers highly specialized medical and surgical services to care for children with conditions ranging from common to the highly complex at our 358-bed stand-alone children’s hospital that includes 28 regional NICU beds. Our family-centered, pediatric services extend from a leading pediatric cancer and blood disorders center home on the West Coast, and a pediatric heart center known for its expertise and pioneering treatments, to a Regional Level IV neonatal intensive care unit (NICU), the highest level referral center between Los Angeles and the Bay Area. We participate in community initiatives, we support community efforts, we get involved where we can do the most good.

EXPERIENCE:

• Minimum 5 years full time equivalent working as a registered nurse in an acute care hospital setting
• Pediatric experience and experience in Utilization Review or Case Management preferred
• Knowledge of Utilization Management regulations and private and public payer reimbursement practices and procedures
• Excellent organizational and communication skills with the ability to work with a variety of healthcare professionals
• Proficiency in word processing, spreadsheets and database software

EDUCATION/LICENSES/CERTIFICATIONS:

• Graduate of an accredited nursing program required
• Bachelor’s in nursing or a field that supports the case management process preferred
• Active California Registered Nurse licensure (RN) required

ADDITIONAL SHIFT DETAILS:

• Position is Monday through Friday 0730 to 1600

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Disclaimer:  Final compensation will be dependent upon skills and experience.