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Nurse (Quality & Safety)-DHA
2 months ago
09/03/2024:This position is being re-announced to solicit additional candidates. Applicants who previously applied to this announcement need not re-apply unless submitting updated information and/or missing forms.
This position is being announced concurrently under Excepted Service Examining Plan (ESEP)/Merit Promotion (MP) procedures. Please review vacancy announcement number IHS-24-GA-12447539-ESEP/MP; for eligibility requirements. NOTE: Applicants must apply separately for each announcement in order to be considered under ESEP/MP.
Process for assessing and monitoring patient charts and health status to determine appropriateness and completeness of medical documentation, length of stay, intensity of services, and allocation and utilization of resources for patient care.
Provide concurrent or retro review to third party payers as needed for certification of admission days as needed. Communicate with providers and nursing staff to ensure accurate clinical documentation is present in the electronic health records.
Review denials for appeal, when received from Case Management. Collaborate with Business Office and Billing staff to track and review ensuring prior authorization has been completed on admission for third party eligible cases.
Works with the Health System Administrator and Clinical Director to resolve complex medical documentation problems. Utilizes Registered Nurse Training and expertise to prevent denials by instructing and training the practitioners regarding complete and appropriate medical documentation for the patient's status and level of care, and that the documentation meets applicable guidelines, standards, policies, procedures.
Assures that the Utilization Review program meets the Joint Commission and third party payer's guidelines and regulatory requirements.
Analyzes and projects fiscal year third party billing/collection based on inpatient per diem rate, outpatient visit rate, Diagnosis Related Groups (DRG) case mix average for inpatient and outpatient, workloads, and available Medicare, Medicaid, and Private insurance population data.
