Job Description

Overview:

WissenCare is a global workforce management provider headquartered in Ann Arbor, Michigan that offers strategic talent solutions to our clients world-wide. This client is a locally based, nonprofit healthcare organization. Their health system includes two hospitals, a 100-provider primary and specialty care medical group, a cancer center; and a new medical fitness center.

Job Title: Clinical Utilization Review Nurse II

Location: Fairfield, CA 94533

Duration: 2 Months

Job Type: Temporary Assignment

Work Type: Remote

Job Description:

Duties:

• The Clinical Utilization Review Nurse II (URN) is an experienced registered nurse who prospectively and concurrently evaluates appropriateness of inpatient and observation services based on clinical documentation, evidence-based guidelines and insurance benefits, and communicates required clinical information to payers in accordance with contractual and regulatory obligations.
• The Level II URN serves as a clinical resource to physicians/providers by providing education related to medical necessity, utilization review and payer requirements.
• Perform comprehensive admission and continued-stay reviews for inpatient and observation cases using facility-approved criteria and payer rules.
• Ensure utilization review documentation is accurate, timely and audit-ready, clearly reflecting clinical facts, criteria application and rationale.
• Identify opportunities for alternative levels of care when criteria are not met.
• Identify short-stay risk, disputed status and medical necessity concerns and escalate to Physician Advisor or leadership as indicated.
• Oversee and ensure the Daily Review Tracker, Ambulatory Surgery list and Observation-to-Inpatient list are consistently maintained, updated and reviewed in a timely manner; validates data integrity, identifies gaps or delays and initiates corrective action as needed.
• Prepare concise clinical summaries for peer-to-peer discussions and payer communications.
• Monitor and report denial trends, avoidable days and utilization issues within assigned workload for continued process improvement.
• Collaborate with revenue cycle on claim issues and appeals.
• Analyze population-specific utilization patterns and communicate issues impacting progression of care.
• Promote use of evidence-based protocols, pathways and order sets to support high-quality and cost-effective care.
• Participate in audits, quality improvement initiatives, shared governance activities and ongoing competency development.

Skills:

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments and performance evaluations.
• Sufficient proficiency in speaking, reading and writing the English language necessary to perform the essential functions of this job, especially regarding activities impacting patient or employee safety or security.
• Ability to effectively communicate with physicians and co-workers in a manner consistent with a customer service focus and application of positive language principles.
• Advanced knowledge of Milliman Care Guidelines and knowledge of local and national coverage determinations.
• Comprehensive knowledge of Medicare, Medicaid and Managed Care requirements.
• Comprehensive knowledge of health care financial and payer requirements/issues.
• Comprehensive knowledge of utilization review, case management, performance improvement, and managed care reimbursement.
• Ability to work independently and exercise sound judgment in interactions with physicians and health care team members.
• Strong assessment, organizational and problem-solving skills; strong time-management and ability to handle high-volume UR reviews without dropping documentation quality.
• Comfort navigating EMRs and UR documentation tools with accurate data entry and audit readiness.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).
• Competent computer skills in Cerner, Adobe and Microsoft Office Suite (Excel, Teams, Outlook, PowerPoint and Word)

Education:

• Graduate of an accredited school of nursing.
• BSN required.
• Current California RN License and Magnet ANCC-recognized Case Management certification (CCM, ACM-NBCM, etc.).
• Minimum of 5 years of clinical nursing experience including 3 years in utilization review/case management.
• Advanced knowledge of Milliman Care Guidelines, Medicare/Medicaid and managed care requirements.

WissenCare Group is an equal opportunity employer supporting workforce diversity.

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