Catholic Health Initiatives RN Registered Nurse Utilization Review - Care Coordination in DES MOINES, Iowa

RN Registered Nurse Utilization Review - Care Coordination

Description

GENERAL SUMMARY :

Responsible

for the review of inpatient and outpatient admission records for appropriate admission

status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending

physician and the Case Management staff utilizing admission criteria guidelines-and

second level physician review process when appropriate. Interacts with insurance providers to obtain

authorization and continued stay approval for admission. Collaborates with the Verification

department, Revenue cycle and Financial Counseling to facilitate the

establishment of the correct payer source for patient stay and the

documentation of the interactions in the STAR admitting system.

ESSENTIALFUNCTIONS :

  • Conductsadmission review per the Utilization Management Plan to ensure that thehospitalization is warranted based on established criteria. Reviewing may be both concurrent or post discharge.

  • Carriesout hospital programs and principles of utilization review in compliance withhospital policies and external regulatory agencies Peer Review Organization(PRO), Joint Commission, and multiple payer defined criteria for eligibility.

  • AppliesMilliman Careguidelines Criteria for appropriate status determination.

  • Engagesin discussion with the attending physician for clarification and/or statuscorrection.

  • Engagessecond level physician review as indicated to support the appropriate status.

  • Ensurestimely communication with Case Management staff for all concurrent statuschanges.

  • AdministersNotice of Status Change to the patient/family when indicated. Provides education and information for thepatient/family for clarification of the change.

  • Documentsin the Medical Record Utilization Management forms accurately to reflect the appropriateadmission criteria and appropriate status along with any communications.

  • Ensurestimely notification to Admitting of status of change or status discrepanciesidentified.

  • Reviewsthe records on admission for status orders present addressing Center forMedicare Services rules and guidelines around admission status.

  • Monitorsinsurance coverage for patients in the STAR admitting/financial system andcommunicates any updates to the Verification Department.

  • Providesclinical information as request from the insurance payer via telephone or faxin a timely manner to prevent technical denials.

  • Entersauthorization, approvals and denials into the STAR systems and communicatespertinent changes to Case Management.

  • Engagesthe attending physician to advocate and communicate via Peer to Peer Review fordiscussion with insurance for admission, continued stay or status whenrequired.

  • Reviewsdenial letters/faxes received in Care Coordination Department and direct toConifer Appeal Department for appeal.Documents in the STAR system.

  • Collaboratesin monitoring and addressing observation outliers and status discrepancies withMedical Records Department and Admitting Department.

  • Collaborateswith the Recovery Audit Contractor (RAC) Coordinator and Conifer for Medicare/MedicaidRAC Denials management.

Qualifications

MINIMUM KNOWLEDGE,SKILLS AND ABILITIES REQUIRED :

  • Currentlicensure as a registered nurse in the State of Iowa.

  • Five(5) years clinical nursing experience.

  • Bachelorof Science - Nursing or degree in healthcare-related field preferred.

  • Proof of completion of Mandatory Reporterabuse training specific to population served within three (3) months of hire.

  • Knowledgeof eligibility requirements for insurance coverage with respect to health careservices: ambulatory, observation stays,surgical, acute care, subacute and continuum of care services.

  • Demonstratedability to manage complex management and clinical situations. Ability to work within a functionindependently exercising judgement to reach resolutions to issues.

  • Specialtycertification in Utilization Review within 12 months of hire preferred.

Job RN

Primary Location IOWA-DES MOINES-MERCY MEDICAL CENTER

Daily Schedule Days

Scheduled Hours per 2-week Pay Period 80

Weekends Required Occasional

Req ID: 2018-R0177494

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.