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RN-Nursing Unit
4 months ago
Full Time 40 Hours Per Week
FACILITY: New Mexico Regional Office
Wexford Health Sources, Inc. is one of the nation's largest correctional health care providers. Over the past 30 years, our team of dedicated clinical professionals has helped literally millions of justice-involved patients receive life-changing medical and mental health services.
In many cases, our doctors, nurses, and behavioral health professionals represent the patient's first experience with quality, compassionate health care.
When you join Wexford Health, you do more than just further your career.
You also become part of a team-a family-whose mission is to care for patients that cannot care for themselves.
If you are looking for a position that empowers you to do MORE... then look at Wexford Health.
Annual review with performance increase
• Paid holidays
• Comprehensive health insurance through Blue Cross Blue Shield
• Dental and Vision insurance
• 401(k) retirement saving plans
• Company-paid short-term disability
• Healthcare and dependent care spending account
The Utilization Management Nurse (RN) ensures cost effective outcomes while maintaining a focus on quality care for inpatient and/or outpatient services. He/she monitors on-going medical needs and services by engaging in the following: evaluating medical necessity, appropriateness and efficient use of Health Care Services for inpatient hospitalizations and/or outpatient procedures, working closely with physicians, hospital utilization management and correctional facilities to provide quality, cost-effective care at the level most appropriate to the inmate-patient; and providing reports and recommendations to medical and facility staff for improved utilization of resources.
Work with patients and providers for the patients' best interests by helping to ensure appropriate care and maximizing clients' medical benefits;
Review clinical information provided by the Hospital Utilization Management Departments for appropriateness of care, medical necessity and appropriate level of care;
and access computer system to obtain reference numbers for hospital billing and claims payments.
Review clinical information with appropriate Medical Director and Director of Nursing to facilitate discharges back to the infirmary.
Work with Operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
Issue notices of non-coverage in conjunction with Statewide UM Medical Director.
Prepare appeals of non-covered services for medical director review and update computer system as appropriate.
Review each region's collegial log for completeness, in preparation for collegial discussion and ensures that consult requests are documented in each patient's medical record
Obtain all necessary clinical information, history, criteria, and present findings to UM Medical Director for inpatient and/or outpatient review.
Provide site and providers with authorization number/letter according to policy.
Pre-certify specific surgical cases as outlined in the policy and procedures.
Review history of all consults and raise question of a possible quality of care issue or risk management issue to UM Medical Director or Director of UM.
Work with Operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
Prepare statistical reports for UR and Operations personnel.
Provide overview of Utilization Management purpose and function to new Health Care Unit Administrators and other site personnel as requested by the Director, Utilization Management.
Assist with orientation of new UM staff and site staff as indicated.
Work with Medical Directors to identify areas of concern and quality improvement
Work with Director of Utilization Management and other UM staff on special projects.
Research inappropriate/administrative transfers of medically unstable inmates
Actively participate in Utilization Management staff meetings.
Collect data to monitor facility compliance to Company standards and policies
Be knowledgeable of Department of Correction Policy/Procedures and Contractual Agreements with providers
The duties and responsibilities outlined herein are for payroll purposes only;
