Point Of Entry Nurse- Case Management
3 weeks ago
Description Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Responsible for collaboration with members of interdisciplinary health care team (physicians, other health care professionals, payers, etc.) to identify appropriate utilization of hospital resources and to ensure timely reimbursement for services rendered; including communication between hospital and third-party payers to ensure hospital services will be reimbursed and denials minimized. The Point of Entry UR nurse will work with patients presenting in the Emergency Department and/or Operating Room. Utilizes established criteria to confirm medical necessity for pre-authorization of services, and use of other hospital services in accordance with Utilization Management Plan, Conditions of participation (CoP) and other federal and third-party payer regulations and guidelines. Collaborates with in-patient Utilization Review RNs and Case Managers to ensure efficient throughput from hospital admission through discharge and to the appropriate post-acute setting. Responsibilities: Compliance and Safety. Constantly maintains an environment of safety to patients, self, and others. As well as compliance to established internal and external policies and procedures and practice standards. Functions in a team-like fashion utilizing approved evidenced-based criteria for the determination of the appropriateness of medical necessity reviews (i.e. - observation/outpatient, inpatient) within 24 hours of patient's admission to the acute care setting. Actively participates in the identification and obtaining appropriate patient status orders by communicating with the patient's attending physician or surgeon in order to ensure timely billing and reduce the risk of reimbursement denials. Communicates with third-party payers to ensure authorization for services is obtained and completes necessary appeals for concurrent or discharged patients. Consults with Physician Advisors to assist with the determination of appropriate status and follow up regarding medical necessity for admission. Utilization Review- Determines the need for the issuance of hospital notices such as, but not limited to, Hospital Issued Notices of Non-coverage (HINNs). Issues notices to patients when the criteria for hospital admission or continued stay is not met or there is a change in patient status. Participates in and facilitates patient/family education and communication as it relates to utilization review information. Collaborates with hospital Case Management staff in facilitating insurance approval for timely post-acute setting transition. Facilitates and completes concurrent and retrospective appeals for third-party payer denials, as necessary and assigned. Education - Maintains working knowledge of and compliance with third party payer regulations and guidelines; and modifies work behavior and practices as necessary to comply with regulations and guidelines. Participates in ongoing educational opportunities to enhance health care team’s knowledge of utilization review activities, including, at a minimum, quarterly education. Communication-Serves as an expert resource regarding utilization review practices, hospital reimbursement, and other job-related matters. Communicates clearly, confidently, and effectively with all levels of hospital stakeholders, including patients, physicians, and payers. Ensures information is communicated in a timely manner. Reports issues and barriers in an efficient, timely, and effective manner to necessary members of department and hospital team. Compliance Standards of Performance - In addition to hospital Standards of Performance, embraces and exhibits Corporate Compliance Standards of Performance: Integrity – committed to conducting ourselves in an ethical manner, with moral compass, and within legal guidelines at all times. Professionalism – demonstrates a high level of professionalism in all opportunities; displays a personal commitment to develop and improve our skills which will serve as the foundation of our knowledge; always honest with our peers and holds ourselves accountable through self-awareness of thoughts, words, and actions; shows respect to everyone by considering the emotions and needs of others which exhibits true professionalism. Collaborativeness – always recognizes the value and skills of others and solicits input and feedback when appropriate; allows others to be part of the process promoting relationships in which all parties are able to cooperate in order to accomplish a shared outcome. Driven – set goals and have a vision for the future; focuses on desired outcomes with perseverance and courage to accomplish goals regardless of obstacles; desires to develop their self by acquiring new skills and abilities through continuous improvement; displays confident calmness under pressure and is not afraid to take risks or make mistakes, while never losing sight of the organization’s mission. Self development - Participates in self evaluation by making notes/comments in the Accountabilities section of the annual review, updating skills checklist, and mutually setting professional goals for achievement. Stays abreast of professional developments through reading related and professional materials, attending seminars, and participating in educational opportunities. Participates in, and assures that, documentation of own continuing education and self-development activities is current and valid, by signing rosters and submitting copies of continuing education certificates as requested. Miscellaneous duties - Performs and completes additional, non-routine, miscellaneous duties and assignments in support of hospital or department needs. Other Information: Education Requirements: ● Bachelor of Nursing. Graduate of an approved nursing program. Master's of Science in Nursing (MSN) preferred Licensure/Certification Requirements: ● Utilization Review or other applicable certification preferred Professional Experience Requirements: ● 2 years of Healthcare/Medical - Acute Care in acute hospital setting Working knowledge in Utilization Review, including managed care / commercial payers and governmental regulatory requirements preferred Job Details Legal Employer: Nash Hospitals Entity: Nash UNC Health Care Organization Unit: NGH Case Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: NASH HC Exempt From Overtime: Exempt: No Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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