Field Care Manage RN

3 weeks ago

New York, United States SUNY Downstate Health Sciences University Full time
strong>Utilization Review Nurse

Job No: 496490
Department: Medical Care Review
Local Title: Utilization Review Nurse
Budget Title: Th Utilization Review and Quality Assurance Senior Coordinator
Work Type: Full Time
Location: Brooklyn, NY
Categories: Administrative, Nursing, Clinical

Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.

Bargaining Unit:

UUP

Job Summary:

The Department of Care Management at SUNY Downstate Health Sciences University is seeking a full-time Utilization Review Nurse / TH Utilization Review/Quality Assurance Senior Coordinator. The successful candidate will:

  • Complete and send initial clinical reviews within 48-hours of admission for medical necessity and appropriate level of care to all applicable payors via Care Management Module, CarePort.
  • Complete and send every 3-days, continuous stay reviews for patients outside of their ELOS, due to changes in medical status in order to justify medical necessity for a continued stay.
  • Perform precertification reviews to establish medical necessity, appropriateness of services, and compliance with regulatory standards, established medical policy, community standards, and the members plan documents.
  • Perform concurrent and retrospective evaluation of inpatient hospitalizations to establish medical necessity, appropriateness of services, and discharge planning needs; coordinates with the medical team to ensure clinically appropriate determinations.
  • Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, forwarding all cases that do not meet these policies and guidelines, to the Medical Director.
  • Identify and suggest alternative solutions including appropriate levels of care delivery or need for negotiations when indicated.
  • Identify, investigate, and report to the medical team, possible quality of care issues discovered during concurrent or precertification reviews.
  • Participate in clinical rounds when applicable, quality improvement projects, continuing education, and medical management programs as required.
  • Act as a liaison to members, participants, providers of care, and when appropriate, to payors.

Required Qualifications:

  • Bachelor of Science in Nursing.

Preferred Qualifications:

  • Graduate Degree in the healthcare field.

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