Medical Care Optimizer RN
7 days ago
Magnet Medical seeks a skilled Medical Care Optimizer RN to join our team. As a key member of our Utilization Review department, you will play a vital role in ensuring the delivery of high-quality patient care while optimizing resource utilization.
Responsibilities- Utilization Review and Clinical Evaluation: Conduct thorough reviews of patient medical records, treatment plans, and clinical data to assess the appropriateness and necessity of care provided. Ensure that medical procedures, tests, and treatments align with established guidelines and criteria.
- Collaboration with Healthcare Providers: Work closely with physicians, case managers, and other healthcare professionals to develop cost-effective patient care plans. Communicate with healthcare teams to discuss discrepancies or concerns regarding resource utilization, care plans, or treatment goals.
- Insurance and Payer Interaction: Collaborate with insurance companies, managed care organizations, and government payers to review cases for coverage, authorization, and reimbursement. Submit necessary documentation and justification to support medical necessity determinations and secure prior authorization for treatments.
- Monitoring of Length of Stay and Discharge Planning: Monitor patient length of stay to identify potential delays in discharge. Work with case management teams to develop appropriate discharge plans, ensuring patients are ready for discharge with necessary resources and follow-up care.
- Compliance and Quality Assurance: Ensure utilization review practices comply with regulatory standards, including The Joint Commission, Centers for Medicare & Medicaid Services, and other state or federal regulations. Maintain up-to-date knowledge of healthcare regulations, coding guidelines, and payer-specific policies.
- Documentation and Reporting: Document findings from utilization reviews in appropriate systems and ensure accurate record-keeping for insurance purposes and quality improvement efforts. Prepare reports on utilization metrics, including hospital admissions, readmissions, and discharge delays, for management review.
- Bachelor's degree in Nursing required.
- Current RN licensure in the United States.
- 1+ year experience in Utilization Review, Case Management, or a related field.
- Strong understanding of clinical care, health insurance guidelines, and hospital operations.
- Excellent communication, analytical, and problem-solving skills.
- Competitive salary: $85,000 - $110,000 per annum
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