Utilization Review/Quality Assurance Coordinator

To monitor all hospital inpatient admissions and stays for conformance to Medicare standards; to provide case coordination among eligibility, authorization, provider contracts and medical aspects of patient care in all potential Medi-Cal cases; and to ensure effective utilization of medical services and appropriate medical service reimbursement.

Receives general supervision from the Deputy Director, Medical Care Services.

Duties may include, but are not limited to, the following:

• Review inpatient admission records to ascertain medical justification for admission; assure that admissions are to the appropriate service and level of care; review patient progress to determine need for continued hospitalization.
• Assist in the coordination of patient transfer from hospital facility to alternate facility as soon as an acute level of care is no longer required.
• Consult with reviewing agencies of fiscal intermediaries including but not limited to Med-Cal, Medicare and private insurance companies regarding reimbursement for medical services.
• Assist with the issuance of cost significant treatment authorizations and regularly review all such authorizations.
• Authorize, with physician concurrence, payment of outside medical care, such as hospitals, nursing homes, physician services and dental services.
• Provide information to medical staff regarding documentation required for reimbursements, program coverage and utilization review activities and processes; work with various medical personnel to interpret utilization review program changes and recommend revisions to operational procedures.
• Assist in the establishment and monitoring of guidelines to evaluate the approval of optional or non-life threatening services.
• Provide case documentation in patient medical records and appropriate administrative records.
• Build and maintain positive working relationships with co-workers, other County employees and the public using principles of good customer service.
• Perform related duties as assigned.

Experience and Training
It is the applicant's responsibility to identify in their application materials how they meet the Minimum Qualifications listed below.

Experience: Three years of responsible registered nursing experience in a clinical setting; one year in a utilization review capacity is desirable.

Training: Equivalent to the completion of the twelfth grade.  Additional specialized training in professional nursing or a related field is desirable.

License or Certificate:

• Possession of a valid license as a Registered Nurse issued by the California Board of Registered Nursing.
• May need to possess a valid driver's license as required by the position.  Proof of adequate vehicle insurance and medical clearance may also be required.

Knowledge of:

• Practices and principles of nursing care.
• General principles and methods of clinical care and medical treatment, including purpose and expected outcomes.
• Utilization review techniques and practices.
• Laws, regulations, policies and procedures relating to government sponsored medical care and other medical aid/assistance programs.
• Modern office procedures, methods and computer equipment.
• Differing cultural, religious, economic and social groups and their relationships to the delivery and acceptance of health care services.
• Services and functions of other social and health agencies/providers relative to public health nursing.

Ability to:

• On a continuous basis, know and understand all aspects of the job; intermittently analyze procedures, reports and patient charts; identify and interpret technical and numerical information; interpret work assignments; and explain policies and procedures to patients and various providers.
• Intermittently, sit while reading reports, records and patient charts; walk, stand, bend, squat or twist when retrieving or returning files and documents; intermittently twist to reach equipment surrounding desk; perform simple grasping and fine manipulation; use telephone and write or use a keyboard to communicate through written means; and occasionally lift light weight.
• Independently interpret rules and regulations and medical records.
• Prepare and maintain accurate records.
• Interpret medical terminology for non-medical personnel performing admission activities.
• Work with various cultural and ethnic groups in a tactful and effective manner.
• Obtain information through interview; deal fairly and courteously with the public; and handle multiple utilization review cases concurrently; work with interruptions.
• Analyze situations quickly and objectively and to determine proper course of action.
• Use a computer, calculator, typewriter, telephone, facsimile machine, postage meter and photocopy machine.

Training & Experience Rating (100%)

Based upon responses to the supplemental questionnaire, the applicant’s education, training and experience will be evaluated using a pre-determined formula.  Scores from this evaluation will determine applicant ranking and placement on the eligible list.

All applicants who meet minimum qualifications will be required to respond to an online Conviction History Questionnaire, which will be sent as a link on their notification that minimum qualifications have been met.  Failure to respond to this questionnaire within (3) three calendar days of the minimum qualification notification will result in disqualification from the examination.

Prior to the date of hire, applicants must undergo a fingerprint test by the Department of Justice, pass a medical examination, which may include a drug screening and possibly a psychological evaluation, sign a constitutional oath and submit proof of U.S. citizenship or legal right to remain and work in the U.S.  For some positions, applicants may also be required to submit proof of age, undergo a background investigation and/or be bonded.

All new permanent employees, with the exception of sworn law enforcement and management, shall be required to join the employee organization or pay an 'Agency Fee' as a condition of employment.

The eligible list(s) resulting from this recruitment may be certified as a substitute list for a substantially similar classification.  For this purpose, a substantially similar classification is one at a lower level in the same classification (example: entry level vs. journey) and/or a similar classification (similar work performed, similar training and experience qualifications required). If you are contacted for an interview by a County department, you will be informed of the classification and other relevant information. If you choose not to interview for a substantially similar classification, you will remain on the eligible list for which you originally applied.

Placer County now offers an expedited process for qualifying certain applicants for interviews. Candidates currently employed, or employed within the last year, by a public agency operating under a personnel civil service or merit system may be eligible to be placed on a Public Agency Eligible List and certified as eligible for appointment to a similar job assignment without going through the examination process. For more information on the Public Agency Eligible List, to download forms, or to apply, please visit our website at: http://www.jobaps.com/placer/sup/abfreenames.asp.

Thank you for your interest in employment with Placer County. Placer County is an equal opportunity employer and is committed to an active nondiscrimination program. It is the stated policy of Placer County that harassment and retaliation is prohibited and that all employees and applicants shall receive equal consideration and treatment. All recruitment, hiring, transfer and promotion will be based on the qualifications of the individual for the positions being filled regardless of sex, sexual orientation, race, color, ancestry, religious creed, national origin, physical disability (Including HIV and AIDS), mental disability, medical condition (cancer or genetic characteristics/information), age (40 or over), marital status, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state or local laws or ordinance. Please contact the Personnel Department at least 5 working days before a scheduled examination if you require accommodation in the examination process. Medical disability verification may be required prior to accommodation.

The following information represents benefits currently available to permanent Placer County employees and may be subject to change.  It is advisable that applicants inquire as to the most current benefit package during hiring interviews or by contacting the Personnel Department.

Click here to view benefits for General bargaining unit