Utilization Review Nurse

4 weeks ago


Ontario, California, United States Kaiser Permanente Full time
Job Summary:

As a Utilization Review Nurse at Kaiser Permanente, you will work collaboratively with physicians to coordinate and screen for the appropriateness of admissions and continued stays. Your expertise will be essential in making recommendations to physicians for alternate levels of care when patients do not meet the medical necessity for inpatient hospitalization. You will interact with patients, families, and other disciplines to coordinate safe and acceptable discharge plans, functioning as an indirect caregiver, patient advocate, and manager of patients in the most cost-effective way without compromising quality. Additionally, you will be responsible for transferring stable non-members to planned healthcare facilities, complying with AB 1203, Post Stabilization notification, and adhering to other duties as described. This role requires the ability to work collaboratively with the multidisciplinary team, multitask, and function in a fast-paced environment.

Essential Responsibilities:
  1. Plans, develops, assesses, and evaluates care provided to members.
  2. Collaborates with physicians, other members of the multidisciplinary healthcare team, and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resource use.
  3. Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
  4. Assesses high-risk patients in need of post-hospital care planning.
  5. Develops and coordinates the implementation of a discharge plan to meet patients' identified needs; communicates the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies.
  6. Reviews, monitors, evaluates, and coordinates patients' hospital stays to assure that all appropriate and essential services are delivered timely and efficiently.
  7. Participates in the Bed Huddles and carries out recommendations congruent with patients' needs.
  8. Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
  9. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient, and non-KFH facilities.
  10. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
  11. Refers patients to community resources to meet post-hospital needs.
  12. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
  13. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines, including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA, and DOL.
  14. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
  15. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
  16. Per established protocols, reports any incidence of unusual occurrences related to quality, risk, and/or patient safety which are identified during case review or other activities.
  17. Reviews, analyzes, and identifies utilization patterns and trends, problems, or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
  18. Coordinates, participates, and/or facilitates care planning rounds and patient family conferences as needed.


  • Ontario, California, United States Prime Healthcare Management Inc Full time

    Job SummaryPrime Healthcare Management Inc. is seeking a highly skilled Utilization Review Technician III to join our team. As a key member of our denial management initiatives, this role will coordinate the utilization review and appeals process, serving as a liaison between teams and responsible for coordinating phone calls, data entry, and tracking data...


  • Ontario, California, United States Prime Healthcare Management Inc Full time

    Job SummaryWe are seeking a highly skilled and experienced Corporate Director of Clinical Utilization Management to join our team at Prime Healthcare Management, Inc. This role will provide comprehensive oversight of the Utilization Review process for our self-insured Employee Health Plans, ensuring alignment with EPO Plan Documents and other applicable...


  • Ontario, California, United States Kaiser Permanente Full time

    Job Summary: As a key member of the Kaiser Permanente team, the Utilization Management Manager plays a critical role in ensuring the efficient and effective delivery of patient care. This position is responsible for managing the day-to-day operations of the Utilization Management Program, ensuring that resources are utilized in a cost-effective and...


  • Ontario, California, United States Kaiser Permanente Full time

    About the RoleWe are seeking a skilled Healthcare Utilization Manager to join our team at Kaiser Permanente in Ontario, California.This nursing position involves working collaboratively with physicians to coordinate and screen admissions and continued stays. The ideal candidate will have experience in an acute care setting or case management and possess...


  • Ontario, California, United States Onward Full time

    Job DescriptionOnward is seeking a skilled Telecom Field Engineer specializing in utility pole analysis to join our engineering team. The ideal candidate will have experience in designing, analyzing, and performing structural calculations for utility poles in the telecommunications industry.Key Responsibilities:Perform structural analysis and calculations...

  • Staff Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job SummaryAs a leader of the healthcare team, the Staff Nurse provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. The ideal candidate will demonstrate performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization.Key...

  • Critical Care Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job Summary: Kaiser Permanente is seeking a skilled Critical Care Nurse to join our team. As a leader in the health care team, you will provide professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. You will demonstrate performance consistent with the Medical Center Vision,...

  • Staff Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job SummaryAs a leader of the healthcare team, the Staff RN provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. The ideal candidate will demonstrate performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization.Key...

  • LVN Case Manager

    4 weeks ago


    Ontario, California, United States Optum Full time

    LVN Case Manager Job SummaryOptum is seeking a skilled LVN Case Manager to join our team. As a key member of our care management team, you will be responsible for ensuring the continuity of care for patients in both inpatient and outpatient settings.Key Responsibilities:Conduct thorough assessments of patients' clinical records to identify care needs and...

  • Nurse Educator

    4 weeks ago


    Ontario, California, United States American Career College Full time

    About the RoleAt American Career College, we are seeking a dedicated and passionate Nurse Educator to join our team. As a faculty member, you will play a vital role in shaping the next generation of nurses by delivering high-quality clinical instruction and fostering a supportive learning environment.ResponsibilitiesDevelop and implement curriculum aligned...

  • Staff Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job SummaryAs a leader of the healthcare team, this Staff RN will provide professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. The ideal candidate will demonstrate performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization.Key...

  • Staff Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job SummaryAs a leader of the healthcare team, this Staff RN will provide professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. The ideal candidate will demonstrate performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization.Key...


  • Ontario, California, United States Maxim Healthcare Service Full time

    Job Summary:We are seeking a skilled Licensed Practical Nurse (LPN) to provide high-quality patient care in the comfort of their own homes. As a LPN with Maxim Healthcare Services, you will have the opportunity to work with pediatric and adult patients, utilizing your nursing skills to assess, plan, implement, and evaluate patient...


  • Ontario, California, United States West Coast University Full time

    Make a Difference in HealthcareJoin West Coast University as a Nursing Faculty member and play a key role in shaping the next generation of nurses. As a certified Great Place to Work, we offer a student-centered, innovative community where you can share your success story and make a lasting impact.Your Responsibilities:Guide nursing students to achieve their...

  • Emergency Room Nurse

    4 weeks ago


    Ontario, California, United States Kaiser Permanente Full time

    Job SummaryAs a leader in the healthcare team, the Emergency Room Nurse provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. The ideal candidate will demonstrate performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization.Key...

  • Electrical Engineer

    4 weeks ago


    Ontario, California, United States Meridia Recruitment Solutions Full time

    Meridia Recruitment Solutions is seeking an experienced Intermediate Electrical Engineer, Roadway Lighting and Traffic Signals to join their team in Toronto or Halton. The ideal candidate will have a strong background in electrical engineering, with a focus on roadway lighting and traffic signals.Responsibilities:* Provide engineering and design services for...

  • Registered Nurse

    4 weeks ago


    Ontario, California, United States Trinity Health Full time

    Job Summary:We are seeking a dedicated Registered Nurse to join our Orthopedic/Medical/Surgical Unit at Trinity Health. As a key member of our team, you will provide exceptional patient care, collaborating with colleagues to ensure the highest quality of care.Responsibilities: Provide hands-on patient care to a variety of patients, promoting their physical,...


  • Ontario, California, United States Kaiser Permanente Full time

    Job Summary:We are seeking a highly skilled Inpatient Pharmacist Specialist to join our team at Kaiser Permanente. As a key member of our pharmacy team, you will be responsible for monitoring and managing the medication therapy of hospitalized patients, providing medication information and pharmacokinetic dosing advice, and adjusting doses and ordering...


  • Ontario, California, United States LanceSoft Full time

    LanceSoft, a leading healthcare staffing firm, is committed to finding the best talent for its clients. With over two decades of experience, we have established ourselves as a trusted partner in the industry.The role we are currently seeking to fill is for a travel nurse RN ED - Emergency Department position in Ontario, California. This is a 13-week contract...

  • Electrical Engineer

    3 weeks ago


    Ontario, California, United States Meridia Recruitment Solutions Full time

    We are seeking an experienced Intermediate Electrical Engineer to join our team in Toronto or Halton office. As an electrical engineer, you will be responsible for providing engineering and design services for electrical systems in multi-disciplinary projects for public and private sector clients.Your Key Responsibilities:Providing technical support at all...