RN Utilization Review - Case Management

Description

Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters!

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Eligibility for benefits may vary by location and is determined by employment status.

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity. This position manages the medical necessity process for accurate and timely payment for services that may require negotiation with a payor on a case-by-case basis.

This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordinating with payors to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Collaborating with Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Educating payors, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits and compliance

The individual's responsibilities include the following activities:

• Securing and documenting authorization for services from payors
• Performing accurate medical necessity screening and timely submission for Physician Advisor reviews
• Collaborating with payors, physicians, office staff and ancillary departments
• Managing concurrent disputes
• Identification and reporting over and under utilization
• Timely, complete, and concise documentation in Tenet Case Management documentation system
• Maintenance of accurate patient demographic and insurance information
• Identification and documentation of potentially avoidable days
• Other duties as assigned

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Completes admission reviews for all payors and sending admission reviews for payors with an authorization process
• Completes concurrent reviews for all payors and sending concurrent reviews to payors with an authorization process
• Closes open cases on the incomplete UM Census
• Completes the Medicare Certification Checklist on applicable admissions
• Discusses with the attending status changes, order clarifications, observation to inpatient changes for all payors
• Reviews the OR, IR and cath lab schedule with follow-up as indicated
• Identifies and documents avoidable days
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements.
• Provides denial information for UR Committee, Denial…