RN Utilization Review OPIS
3 weeks ago
ABOUT NCH
NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.
NCH is transforming into an Advanced Community Healthcare System(TM) and we’re proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.
Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there's always more at NCH - for you and every person we serve together. Visit nchjobs.org to learn more.
JOB SUMMARY
The RN Utilization Review coordinates care for OPIS patients who are high cost, complex, and at risk. The goals are to assess, refer, evaluate and monitor progress to provide efficient and cost effective care while maintain patient satisfaction. It will also require reviewing third party reimbursements and billing procedures to assure hospital’s ability to receive payment for services rendered in a timely fashion. Collaborate with nurses, physicians, case managers and social workers when potential payer concerns will affect treatment plan and duration of services.
ESSENTIAL DUTIES AND RESPONSIBILITIES
– Other duties may be assigned.
· Reviews medical records and orders for medical necessity. Refers cases to administration as appropriate. Issues notices for non-coverage as needed.
· Serves as a liaison between hospital and payer to obtain pre-authorization confirmation and enters into medical record/billing system timely and accurately.
· Collaborates with third party payers confirm patient co-pay, deductible, out of pockets expenses and insures that patient is aware of financial responsibility.
· Communicates with physicians to ensure that correct clinical data is documented to gain proper pre-authorization for third party payers.
· Communicates to clinical staff when pre-authorizations are obtained so that appointments can be made in timely to meet patient needs.
· Assist patients to complete various financial forms in collaboration with business office.
· Works with business office to resolve payment denials.
· Makes referrals to the Case Manager of compassion drug program as appropriate.
· Participates in Oncology rounds/patient care conferences.
· Assists with data analysis and report preparation to track payer mix and reimbursement.
· Provides counseling/guidance to clients and families.
· Refers clients/families to appropriated agencies/service providers.
· Review medical records for knowledge/understanding of situation and resource assessment. Monitor costs, avoidable treatments and resource utilization. Documentation and data is concise and timely.
· Knowledge of community resources and referrals to insure patient satisfaction and reduce costs. Participates in focused studies to resolve patterns in aggregate variances. Understands the principles and concepts of Performance Improvement. Look for opportunities and solutions for process improvement and seeks to improve job skills.
· Keeps current regulatory and accreditation requirements. Works to ensure those standards are met through staff education. Maintains the principles of confidentiality. Understands the legal/regulatory requirements related to the release of information. Able to use information systems pertinent to the job.
· Displays positive leadership traits, serves as a resource to staff and physicians. Participates in staff meetings, clinical team meetings and other meetings as necessary to support goals and outcomes. Identifies system problem/barriers and effectively negotiates completion of tasks with successful conflict resolution. Actively assists and supports departmental activities to ensure that operational and salary expenses are equal to or less than approved budget.
· Communicates verbally and in writing in clear and concise manner. Demonstrates team facilitation skills. Utilizes communication equipment effectively.
· Maintains understanding of various payers and Medicare pre-authorization processes.
EDUCATION, EXPERIENCE AND QUALIFICATIONS
· Minimum of High School or GED required, Associate Degree preferred.
· Licensed as a Registered Nurse (RN) in the State of Florida
· Minimum of 1 year of experience in a related field required.
· Intermediate computer knowledge: Uses Microsoft Word, Excel, Outlook, and Windows
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