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Clinical Nurse Specialist
2 months ago
As a Registered Nurse at Meadville Medical Center, you will play a crucial role in Utilization Management (UM). This involves assessing the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities in accordance with the applicable health benefits plan.
Key Responsibilities:
1. Conduct prior authorizations to ensure that healthcare benefits are managed effectively by evaluating the appropriateness of services before they are rendered.
2. Collaborate extensively with physicians, nursing staff, and medical records coding teams to enhance clinical documentation, ensuring it accurately reflects the patient's severity of illness and complexity of care.
3. Serve as an Employee Insurance Liaison, working with Human Resources and medical directors to review out-of-network procedures and assist employees in navigating the waiver process.
4. Analyze medical necessity rules, urgency, and patient medical history to make informed decisions regarding healthcare services.
5. Engage in ongoing education for healthcare providers about the importance of accurate clinical documentation and its impact on reimbursement and patient outcomes.
Qualifications:
- Must possess a valid Registered Nurse license in good standing, with proof of successful completion of educational requirements.
- A minimum of 5 years of experience as a Registered Nurse is required.
- Strong analytical skills to interpret complex documents and regulations.
- BLS certification is mandatory, and certification in UM nursing and Clinical Documentation Improvement (CDI) is highly encouraged.
Desired Attributes:
- Detail-oriented with a commitment to lifelong learning.
- Ability to establish effective relationships with interdisciplinary teams, patients, and their families.
- Proficient in utilizing coding nomenclature and understanding the implications of coded data on healthcare reimbursement.
Goals:
- Enhance the quality of care and life for patients.
- Promote cost-effective medical outcomes and continuity of care.
- Participate in patient rounding and collaborate with coding professionals to ensure accurate documentation.
- Maintain meticulous records of all communications and interventions.
We are looking for a dedicated professional who is passionate about improving healthcare delivery and patient outcomes.
