UTILIZATION/QUALITY REVIEW NURSE

2 weeks ago

Granger IN USA, United States Beacon Health System Full time
PRN

3245 Health Drive

Professional

Day

Reports to the Director, Managed Care and Medical Director of Community Health Alliance (CHA). Conducts effective utilization and quality review through the monitoring of care provided during hospitalization and certain out-patient procedures according to utilization management guidelines for workers compensation and group accounts. Review includes pre-certification, admission, concurrent discharge and retrospective review on assigned accounts. Review may also include focused or targeted monitoring of out-patient services and physician office visits. Utilizes a case management approach. Also responsible for medical claims analysis through proper identification.

MISSION, VALUES and SERVICE GOALS

* MISSION: We deliver outstanding care, inspire health, and connect with heart.
* VALUES: Trust. Respect. Integrity. Compassion.
* SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Conducts effective utilization and quality review by:

* Maintaining accurate records, informing callers of where to call for benefits, assisting with appropriate referrals and identifying, before or at the time of admission, cases which are at high risk for discharge planning intervention.
* Educating providers regarding the purpose and goals of the programs and conducting appropriate referrals and follow-up on those cases which necessitate the use of a physician advisor; referring all cases which do not meet severity of illness-intensity of service criteria.
* Assisting in large case management and acting as a consultant in the medical analysis or refers all potential large cases to the appropriate outside case management Company.
* Striving, consistently, to enhance the review process through new knowledge and trial of innovative techniques, while maintaining confidentiality under HIPAA Guidelines.
* Conducting pre-certification of admissions or potential admission utilizing established guidelines, determining appropriateness of admission.
* Obtaining provider information on pre-certification and concurrent review, maintaining positive working relationships with preferred providers and payors and generating reports related to the UR/QA activity.
* Directing patients to appropriate providers through the pre-certification and review activity and establishing methods of data collection and monitoring to reflect UR/QA activity.
* Reassessing claim decisions when requested by the physician, employer or UR/QA Committee and striving, consistently, to enhance the medical analysis of claims through new knowledge and trial of innovative techniques.
* Assisting in the appeals process.
* Conducting and maintaining cases that are under the case management program. Establishes methods of data collection and monitoring to reflect utilization review and quality assurance activity.

Contributes to the overall effectiveness and efficiency of the department by:

* Maintaining accurate records, including monthly and year-to-date utilization statistics utilizing appropriate medical terminology and in accordance with established policies and procedures.
* Referring provider issues to the Medical Director or Director when follow-up is needed such as: patient or provider complaints, inappropriate billing practices or utilization problems.
* Maintaining working relationships with contracting providers, accounts, patients and employees; establishing and maintaining direct contacts to enhance the day-to-day operation of the UR/QA program.
* Participating in meetings and on committees as requested; attending all Health Resource Management Committee meetings
* Undertaking verbal and written communications to Hospital associates, physician's offices, UR/QA Committee and others, as necessary.
* Providing the Medical Director and Director with timely written and verbal communications, as requested.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

* Completing other job-related assignments and special projects as directed.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

* Attends and participates in department meetings and is accountable for all information shared.
* Completes mandatory education, annual competencies and department specific education within established timeframes.
* Completes annual employee health requirements within established timeframes.
* Maintains license/certification, registration in good standing throughout fiscal year.
* Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
* Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
* Adheres to regulatory agency requirements, survey process and compliance.
* Complies with established organization and department policies.
* Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

* Leverage innovation everywhere.
* Cultivate human talent.
* Embrace performance improvement.
* Build greatness through accountability.
* Use information to improve and advance.
* Communicate clearly and continuously.

Education and Experience

* The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a nursing program from an accredited school of nursing; an undergraduate degree preferred. A minimum of two years experience in an acute care facility with at least one year of experience with utilization review, coding and/or case management is required. Previous experience with various reimbursement entities and/or claims management with a basic knowledge and understanding of Managed Health Care Programs (such as PPO, HMO, IPA, etc.) is required.

Knowledge & Skills

* Requires a thorough knowledge of Millimam and Robertson criteria, medical terminology and record systems and a strong understanding of managed care.
* Demonstrates the analytical skills necessary to analyze and compile data and generate reports accurately representing trends and information of utilization experience.
* Demonstrates the interpersonal and communication skills (both verbal and written) necessary to interact effectively to patients, visitors and physicians.
* Requires proficiency in basic computer skills (i.e., data entry, word processing, spreadsheets and data base applications).
* Requires the ability to pay attention to details, organize and prioritize work independently and utilize available resources.

Working Conditions

* Works in an office environment.

Physical Demands

* Requires the physical ability and stamina to perform the essential functions of the position.

  • UTILIZATION REVIEW NURSE

    3 weeks ago

    Portland, ME 04101, USA, United States Martin's Point Health Care Full time

    Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of people caring for people, Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an...

  • UTILIZATION REVIEW NURSE

    3 weeks ago

    Milford, MA 01757, USA, United States Milford Regional Medical Center Full time

    Per diem, 8a-4;30P as needed weekends + occ/ holidays About Us Milford Regional Medical Center is a full-service, community and regional teaching hospital located in Milford, Mass. and serves patients from more than 20 towns in Central Massachusetts. The 149-bed medical center is a nonprofit, acute-care facility, where more than 300 primary care and...

  • UTILIZATION REVIEW NURSE

    3 weeks ago

    Meadowbrook, PA 19006, USA, United States Holy Redeemer Health System Full time

    Per Diem1648 Huntingdon PikeNursing RN/LPNDaySUMMARY OF JOB:To review each admission for appropriate assignment of level of care based upon clinical guidelines as well as to review documentation for continued stays daily and provide clinical information including assessments and outcomes for all payers and all levels of care as required by the payer. Work...

  • UTILIZATION REVIEW NURSE

    3 weeks ago

    Moscow, ID 83844, USA, United States Gritman Medical Center Full time

    Job Summary:At Gritman, we pride ourselves on being the premier healthcare employer on the Palouse. We bring exceptional care that's close to home for the members of our community. We are seeking a Staff RN to join our Utilization Review/Case Management team. The Utilization Review Nurse (UR) has skills in areas of Utilization Management (UM), medical...

  • UTILIZATION REVIEW NURSE

    1 week ago

    Huntsville, TX 77340, USA, United States Huntsville Memorial Hospital Full time

    Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and...

  • PCS CASE MANAGER/UTILIZATION REVIEW NURSE

    1 week ago

    Decatur, IN 46733, USA, United States Adams Memorial Hospital Full time

    The PCS Case Manager/Utilization Review Nurse (UR) is responsible for monitoring and justifying the acute level of care according to criteria established by State and Federal regulatory agencies, insurance companies, and other third-party payers. Through ongoing open chart review, the PCS Case Manager/Utilization Review Nurse helps facilitate the...

  • UTILIZATION REVIEW NURSE

    1 week ago

    Jacksonville, IL 62650, USA, United States Taylorville Memorial Hospital Full time

    OverviewAs a Utilization Review Nurse, you will work under the direct supervision of the Supervisor, Utilization Review and Clinical Documentation Improvement, this role will be responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. This...

  • UTILIZATION REVIEW RN

    6 days ago

    Richmond, VA, USA, United States VCU Health Full time

    The Utilization Review RN is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review.This position functions as a part of a multidisciplinary team, including physicians, social workers, discharge planning assistants and payers. The Utilization Review RN performs reviews of current inpatient services,...

  • UTILIZATION REVIEW NURSE

    1 week ago

    San Angelo, TX 76903, USA, United States Shannon Health Full time

    Job SummaryThe Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and...

  • REGISTERED NURSE UTILIZATION REVIEW

    3 weeks ago

    Irving, TX, USA, United States CornerStone Full time

    CornerStone Medical is looking for a Registered Nurse Utilization Review for a state of the art hospital system in Irving, TX. This is an onsite role. Current RN Compact License required 8 am - 5 pm Monday - Friday $37/ Hr Summary: The RN Utilization Registered Nurse, Registered, Nurse, RN, Clinical, Healthcare, Staffing

  • UTILIZATION REVIEW RN

    1 week ago

    Dallas, TX 75231, USA, United States TEXAS INSTITUTE FOR SURGERY Full time

    Job DetailsJob LocationTexas Institute for Surgery LL SURG - Dallas, TXSalary Range$38.00 - $43.00 HourlyJob CategoryHealth CareDescriptionJob Summary:The Utilization Management Nurse will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorizations. This role performs telephonic and/or concurrent...

  • NURSE CONSULTANT UTILIZATION REVIEW

    3 weeks ago

    Franklin, TN 37068, USA, United States Arthur J. Gallagher & Company Full time

    Provides utilization management review of worker's compensation claims . Accesses medical documentation and information provided by medical providers to determine the appropriateness of treatment, setting and length of treatment required. Essential D Nurse, Consultant, Insurance, Healthcare, Treatment, Medical

  • UTILIZATION REVIEW LVN

    2 weeks ago

    Bakersfield, CA 93309, USA, United States CommonSpirit Health Full time

    ***This position is remote with a clear and current CA LVN license.  The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale...

  • UTILIZATION REVIEW RN

    4 weeks ago

    Omaha, NE 68102, USA, United States Common Spirit Full time

    OverviewUtilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the...

  • UTILIZATION REVIEW RN

    1 week ago

    Omaha, NE 68182, USA, United States Catholic Health Initiatives Full time

    **Overview**Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the...

  • UTILIZATION REVIEW NURSE

    1 week ago

    Corona, CA 92879, USA, United States KPC Global MSO Full time

    Victor Valley Global Medical CenterVictorville, CACoordinates and reviews all medical records, as assigned to caseloadActively participates in Case Management and Treatment Team meetingsServes as on-going educator to all departmentsResponsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is...

  • REGISTERED NURSE RN

    2 weeks ago

    Pensacola, FL 32501, USA, United States Ascension Health Full time

    Details* Department: Utilization Mgt* Schedule: M-F 8 hr days, ONSITE, exempt* Hospital: Ascension Sacred Heart Pensacola* Location: Pensacola, FloridaBenefitsPaid time off (PTO)Various health insurance options & wellness plansRetirement benefits including employer match plansLong-term & short-term disabilityEmployee assistance programs (EAP)Parental leave &...

  • REGISTERED NURSE RN

    1 week ago

    Pensacola, FL 32505, USA, United States Ascension Health Full time

    **Details**+ **Department: Utilization Mgt**+ **Schedule: M-F 8 hr days, ONSITE, exempt**+ **Hospital: Ascension Sacred Heart Pensacola**+ **Location: Pensacola, Florida****Benefits**Paid time off (PTO)Various health insurance options & wellness plansRetirement benefits including employer match plansLong-term & short-term disabilityEmployee assistance...

  • UTILIZATION REVIEW NURSE, FT DAYS

    3 weeks ago

    El Paso, TX 79910, USA, United States El Paso Children's Hospital Corporation Full time

    To monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse...

  • REGISTERED NURSE

    3 days ago

    Sitka, AK 99835, USA, United States Southeast Alaska Regional Health Consortium Full time

    Pay Range:$46.87 - $64.18SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.Working at SEARHC is more than a job, it's a fulfilling career....