Weekday Insurance Utilization Review Jobs in California

Mad River Community Hospital seeks a Utilization Review Coordinator. This position reports to the Chief People and Compliance Officer. The Utilization Review Coordinator is responsible for facilitating, coordinating, integrating and evaluating utilization review activities within the inpatient acute care setting. The UR Coordinator is part of a team that is accountable for facilitating and providing care coordination services and quality outcomes for patients through discharge planning and transitional care.
The Utilization Review Coordinator serves as the primary coordinator for the Swing Bed Program, and works collaboratively with the CNO, Nursing staff Case Management, Therapy, Physicians, House Supervisors, and other members of the interdisciplinary team.
RESPONSIBILITIES:
• Collaborates and coordinates with health plans and providers/care teams to ensure appropriate utilization of resources and timely discharge.
• Provides clinical review for different healthcare services requiring authorization, including acute inpatient, skilled nursing facility, acute rehab, and home nursing.
• Communicates with insurance representatives and third party payers to ensure appropriate authorization for care.
• Collaborates and communicates with the care team to develop comprehensive discharge/transitional care plans based on assessment of the patient's clinical and social needs.
• Demonstrates awareness and ability to articulate legal issues pertaining to patient and families, especially related to non-covered stay. Issues denial letters as appropriate following approved procedures.
• Reviewing the recommended patients daily to identify their candidacy for potential Swing Bed admission.
• Coordinating the Swing Bed admission process from identification through admission.
• Verifying eligibility and ensuring regulatory and payer requirements are met.
• Collaborating with physicians, nursing, therapy, case management, and house supervisors to facilitate timely transitions from acute care to Swing Bed.
• Monitoring pending admissions and identifying barriers that may delay placement.
• Coordinating and monitoring required documentation to ensure compliance with Medicare, payer, and hospital requirements.
• Reviewing the Administrative days with Partnership.
• Serving as a resource for staff regarding Swing Bed eligibility, workflow, and documentation requirements.
• Working with the interdisciplinary team to support patient throughput, optimize bed utilization, and facilitate timely discharge planning.
• Monitoring program performance and identifying opportunities for process improvement.
POSITION QUALIFICATIONS:
• Bachelor or master's degree in nursing, Social Work, Sociology, or related field from an accredited school.
• Current clinical licensure, either Registered Nurse or Licensed Clinical Social Worker, preferred.
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab preferred.
• Two to five years of recent acute care clinical experience.
• Working knowledge of DRG classification system, CPT coding, and INTERQUAL.
• Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.
• Capable experience in using electronic medical records.
• Basic proficiency with MS Office, Word and Excel.
• Current BLS certificate.
To Apply:
Please apply via our Portal by clicking the link "Apply Now".
Employment with MRCH is contingent upon passing a post-offer, pre-employment background check and drug screen.
Mad River Community Hospital: A Unique Acute Care Facility
The friendly university city of Arcata, CA is home to Mad River Community Hospital, nestled between the redwoods and the Pacific Ocean, just minutes away from a river, bay, beaches and forests. Mad River Community Hospital is committed to providing the best care for our patients and a balanced work-life integration for our staff.
In addition to acute care and surgical services, the hospital provides emergency services. The hospital operates several outpatient clinics, including surgery, orthopedic, occupational health, pain management, wound care, behavioral health, three primary care clinics, and two physical therapy/sports rehabilitation clinics in Arcata and Willow Creek. There is a 2-acre on-site farm that provides our cafeteria with produce for serving patients and staff.
Equal Opportunity Employer
Mad River Community Hospital provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, national origin, age, sex, sexual orientation, gender identity, disability or genetics. In addition to federal law requirements, Mad River Community Hospital complies with applicable state and local laws governing nondiscrimination in employment. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Humboldt County - Northern California Redwood Coast
The friendly university city of Arcata, CA is home to Mad River Community Hospital, nestled between the redwoods and the Pacific Ocean, just minutes away from a river, bay, beaches and forests. Arcata is an open-minded and welcoming small city, valuing diversity, culture, art, entrepreneurship, and the protection of its beautiful natural environment. Arcata is just 80 miles south of the Oregon border and 275 miles north of San Francisco, known for clean ocean air, moderate temperatures and beautiful landscapes with giant redwoods, flowing rivers and farmlands.
Our Community
Humboldt County is home to a vibrant community and culture, with beautifully preserved Victorian-era historic towns and more artists per capita than any other county in California. Arcata offers a mild climate year-round, with many amenities of larger cities but with a small-town feel and strong sense of community. Our community is rich in the arts: music, theater, and dance performances, art galleries, and hand-crafted woodwork, textiles, and visual artwork in all mediums.
Arcata is just minutes away from pristine mountains, clean, uncrowded Pacific beaches and six mountain-fed rivers. Outdoor adventures abound: cycling, fishing, kayaking, rafting, rock climbing, agate hunting, beachcombing, camping, hiking, backpacking, surfing, golfing and more. With more old-growth redwoods and stretches of undeveloped coast than anywhere else in California, Humboldt County easily earns its rank among the top US destinations and one of the most beautiful counties in the U.S.
Arcata is known for a variety of locally owned specialty farm-to-table cafes and restaurants, serving exquisite, award-winning foods, wines, microbrews, and spirits, many of which are also available in our local markets. Community farms sell their fresh organic produce and flowers at the weekly farmer's market, where you can also find many more locally made goods and sundries.
Arcata is home to California State Polytechnic University, Humboldt - one of only three Polytechnic universities in California. Cal Poly Humboldt offers bachelors, masters and credential programs in a wide variety of majors, including a STEM program. Our K-12 school system is outstanding and offers options of public, charter, and private schools that provide a variety of programs and initiatives for youth of all ages.
The local airport is serviced by United Airlines/Skywest and Avelo Airlines, with daily flights to San Francisco, Los Angeles, Burbank, and Denver, Colorado.
With all this going for it, it's easy to see why so many call the North Coast home!