OverviewFounded in 1910 Dignity Health - Community Hospital of San Bernardino is a 347-bed acute care nonprofit community hospital located in San Bernardino California. Known for its programs in maternity care and pediatrics behavioral health and long-term subacute care for adults and children the hospital also includes inpatient and outpatient surgery. The hospital shares a legacy of humankindness with Dignity Health one of the nation’s five largest health care systems. Visit https://www.dignityhealth.org/socal/locations/san-bernardino for more information.ResponsibilitiesThe Utilization Review Specialist is responsible for reviewing medical records to ensure appropriate admission status and continued hospitalization. This role collaborates with attending physicians, consultants, second-level physician reviewers, and Care Coordination staff, using evidence-based guidelines and critical thinking to support patient care and optimize resource utilization.Key Responsibilities:
Review medical records to evaluate appropriate admission status and continued stay criteria.
Work with Concurrent Denial RNs to analyze the root causes of denials and implement strategies for denial prevention.
Collaborate with Patient Access to verify the correct payer source and document interactions for patient stays.
Obtain inpatient authorizations or provide clinical guidance to Payer Communications staff to facilitate effective communication with insurance providers for admission and continued stay authorizations.
This position requires strong analytical skills, attention to detail, and the ability to effectively collaborate with interdisciplinary teams to support the organization’s mission and ensure compliance with payer requirements.Qualifications
Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
California RN license.
AHA BLS
Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.
Proficient in application of clinical guidelines (MCG/InterQual) preferred
Knowledge of managed care and payer environment preferred.
Must have critical thinking and problem-solving skills.
Collaborate effectively with multiple stakeholders
Professional communication skills.
Understand how utilization management and case management programs integrate.
Ability to work as a team player and assist other members of the team where needed.
Thrive in a fast paced self-directed environment.
Knowledge of CMS standards and requirements.
Proficient in prioritizing work and delegating where indicated.
Highly organized with excellent time management skills.
Preferred
Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
At least five (5) years of nursing experience.
Certified Case Manager (CCM) Accredited Case Manager (ACM-RN) or UM Certification
Pay Range$51.98 - $67.83 /hourWe are an equal opportunity/affirmative action employer.