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Nurse (Quality & Safety) - ESEP/MP
2 months ago
This position is located within the Indian Health Service, Division of Quality Management, at the Gallup Indian Medical Center in New Mexico.
Job SummaryWe are seeking a skilled Nurse (Utilization Review) to join our quality management team. As a key member, you will be responsible for planning, organizing, implementing, and evaluating the functions and requirements of the utilization review.
Key Responsibilities- Provide technical consultation and advice to healthcare teams on policies and procedures related to performance improvement.
- Collaborate with management, medical and administrative staff, and supervisors to initiate corrective actions.
- Conduct concurrent or retro review to third-party payers as needed for certification of admission days.
- Communicate with providers and nursing staff to ensure accurate clinical documentation is present in the electronic health records.
- Review denials for appeal, when received from Case Management.
- Collaborate with Business Office and Billing staff to track and review ensuring prior authorization has been completed on admission for third-party eligible cases.
- Work with the Health System Administrator and Clinical Director to resolve complex medical documentation problems.
- Utilize Registered Nurse Training and expertise to prevent denials by instructing and training the practitioners regarding complete and appropriate medical documentation for the patient's status and level of care.
- Ensure that the Utilization Review program meets the Joint Commission and third-party payer's guidelines and regulatory requirements.
- 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.
- A graduate or higher level degree, bachelor's degree, associate degree, or diploma from an accredited professional nursing educational program is required.
- 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 is required.
- 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.
- This position has an education requirement. You are strongly encouraged to submit a copy of your transcripts or a list of your courses including titles, credit hours completed, and grades.
- Official transcripts will be required from all selectees prior to receiving an official offer.
- This position is covered by a Bargaining Unit.
- Recruitment or relocation incentives may be authorized.
- You will be required to sign a service agreement.
- This position has promotion potential.
