Nurse (Quality & Safety) - DHA

5 days ago

Gallup, New Mexico, United States Indian Health Service Full time
Job Summary

This position is located with the Division of Quality Management at the Gallup Indian Medical Center in Gallup, NM. The purpose is to serve as the Nurse (Utilization Review) responsible for planning, organizing, implementing, and evaluating the functions and requirements of the utilization review.

Key Responsibilities
  • Provide technical consultation and advice on utilization review processes and methodologies.
  • Compile, analyze, and interpret data to monitor and improve revenue collections and compliance with Federal and State agencies.
  • Assess and monitor patient charts and health status to determine appropriateness and completeness of medical documentation, length of stay, intensity of services, and allocation and utilization of resources for patient care.
  • Communicate with providers and nursing staff to ensure accurate clinical documentation is present in the electronic health records.
  • Review denials for appeal and collaborate with Business Office and Billing staff to track and review prior authorization for third-party eligible cases.
  • Work with the Health System Administrator and Clinical Director to resolve complex medical documentation problems.
  • Analyze and project fiscal year third-party billing/collection based on inpatient per diem rate, outpatient visit rate, Diagnosis Related Groups (DRG) case mix average for inpatient and outpatient, workloads, and available Medicare, Medicaid, and Private insurance population data.
Requirements
  • Selectee may be subject to a probationary period.
  • U.S. Citizenship is required.
  • Selective Service Registration is required for males born after 12/31/1959.
  • This is a designated position covered by Public Law, requiring contact or control over Indian children.
  • Confidential Financial Disclosure Form required.
  • Measles and Rubella immunization required for selectees born after 1957 and seasonal influenza immunization is required for all staff working in Indian Health Service health care facilities.
  • COVID-19 vaccination is required for all selectees prior to entrance on duty.
  • The selected individual is required to obtain and maintain any licensure requirements.
  • Successfully pass the E-Verify employment verification check.
Qualifications

To qualify for this position, your resume must state sufficient experience and/or education to perform the duties of the specific position for which you are applying.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; social).

You will receive credit for all qualifying experience, including volunteer and part-time experience.

You must clearly identify the duties and responsibilities in each position held and the total number of hours per week.

BASIC REQUIREMENT(S): Education: A graduate or higher level degree, bachelor's degree, associate degree, or diploma from an accredited professional nursing educational program is required.

This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained.

Degree from Foreign Nursing School: Official certification from the Commission on Graduates of Foreign Nursing Schools is required for individuals who graduated from foreign nursing schools.

Licensure: For all grade levels and positions, applicants must have passed the National Council Licensure Examination.

In addition, they must possess a current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.

MINIMUM QUALIFICATIONS: GS-12: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks:

experience that promotes the coordination, collaboration, and continuity of care from admission to discharge, assess the level of care needed, appropriateness and length of stay; provides education regarding third-party billing reimbursement requirements and liabilities; monitors admissions to meet accreditation requirements; conducts final review and coordinate of discharge/case management plans and familiarity with third-party resources eligibility criteria; including the patient referred care regulations.

Provides consultation and guidance to health care teams on policies and procedures related to performance improvement.

Collaborates with management, medical and administrative staff, and supervisors to initiate corrective actions.

You must meet all qualification requirements within 30 days of the closing date of the announcement.

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