Medical Claims Review Manager jobs in Bakersfield, CA

Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care.  Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year.

Career Opportunities within Kern Medical include many benefits such as:

• New Hire Bonus: $6,000.00
• New Hire Premium: 6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan.
• Shift Differential Pay: 10% of base pay for hours worked from 7:00 PM to 7:30 AM, with two (2) hour minimum.
• A Comprehensive Benefits Package: includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance.

Position: Utilization Review Nurse  - Case Management - Shift

Compensation:

The estimated pay for this position is $41.3155 to $65.1007. The rates shown include a 6% premium pay (base= $37.7500 - $59.4826 plus 6%). This reflects only a portion of the total compensation package for this position. Additional compensation may be available for this role through differentials, incentives, and bonuses. In addition, this position may be eligible for participation and company contributions into the Kern County Employees’ Retirement Plan.

Definition:

Under supervision, to provide and implement a hospital utilization review and discharge planning program; and to do related work as required.

Distinguishing Characteristics:

Positions in this classification are assigned to the Utilization Review division of Kern Medical Center. Incumbents perform clinically oriented medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement and facility accreditation standards. The Utilization Review Nurse classification ranges from less experienced nurses, who will perform administrative tasks concerning Utilization Review and Discharge planning activities, to experienced nurses who will apply full working knowledge of applicable regulations and to develop knowledge of outside agencies and services to develop appropriate discharge plans.

Essential Functions:

• Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present.
• Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions.
• Conducts on-going reviews and discusses care changes with attending physicians and others.
• Formulates and documents discharge plans.
• Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources
• Identifies pay source problems and provides intervention for appropriate referrals
• Coordinates with admitting office to avoid inappropriate admissions.
• Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary.
• Reviews and approves surgery schedule to ensure elective procedures are authorized.
• Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services.
• Answer questions from providers regarding reimbursement, prior authorization and other documentation requirements.
• Learns the documentation requirements of payor sources to maximize reimbursement to the hospital
• Initiates and completes Disease Related Groups (DRG's) for Medicare payment; answers questions from providers regarding reimbursement, prior authorization and other documentation requirements.
• Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital.
• May assist in training of other Utilization Review Nurses.
• Keeps informed of patient disease processes and treatment modalities.

Other Functions:

• Performs other job related duties as required.

Employment Standards:

Possession of a valid license as a Registered Nurse in the State of California

AND

Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, at least one of which was on a medical/surgical ward or unit.

OR 

Possession of a valid license as a Registered Nurse in the State of California, two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, including at least one (1) year on a medical/surgical ward or unit 

AND

one (1) year of utilization review/discharge planning experience in an acute care hospital or as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization review or discharge planning. 

OR

Possession of a valid license as a Registered Nurse in the State of California and two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization or discharge planning.

Incumbents may be required to possess and maintain specific certificates competency based on unit specific requirements as a condition of employment.

Appointees not possessing the American Heart Association Provider Basic Life Support (BLS) card at time of hire must successfully complete appropriate training and qualify for the RQI Provider certification within 60 days of employment. As a continued condition of employment, employee must maintain RQI Provider certification and competency.

Knowledge of:

Payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient disease processes and the usual methods for treating them; knowledge of medical terminology, hospital routine and commonly used equipment; knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services;

Ability to:

Effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans; ability to assess and judge the clinical performance of physicians and other health professionals; ability to communicate documentation needs in an effective and tactful manner that promotes cooperation; ability to gather and analyze data and prepare reports and recommendations based thereon; ability to get along with physicians, other health providers, outside payor sources and the general public.

Supplemental:

A background check may be conducted for this classification.

All Kern County employees are designated "Disaster Service Workers" through state and local laws (CA Government Code Sec.3100-3109 and Ordinance Code Title 2-Administration, Ch. 2.66 Emergency Services). As Disaster Service Workers, all County employees are expected to remain at work, or to report for work as soon as practicable, following a significant emergency or disaster.

If position responsibilities require driving a personal vehicle, then possession of a current valid California Driver’s License and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required.

If position responsibilities require driving a vehicle owned, leased or rented by Kern Medical, then possession of a current valid California Driver’s license, a signed authorization for Release of Drivers Record Information and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required.