Catholic Health Initiatives RN-Utilization Review in LEXINGTON, Kentucky
Position Summary: Responsible for Utilization Review formedical necessity and level of care for patients accessing services at St.Joseph Hospital and St. Joseph East, though the application of InterQualCriteria and other resources as necessary. Determines correct patient statusand obtains order from admitting physician. Cooperates with outside vendor onMedicare/Medicaid Observation vs.Admission status . Communicates with commercial payers with demographic and clinicalinformation as contract requires. IssuesABNs and HINNs as needed per CMS guidelines. Enters complete clinical and payerinformation into MIDAS system. Facilitates action plans regarding denialmanagement for all payers. Performs other duties as instructed by DepartmentDirector and or Department Manager.
Requirements: Education, Credentials, Licenses: MinimalQualifications: RN with AD in Nursing, with UR experience. Experience withInterQual and UR. Desired Qualifications: 3-5 years recent acute careexperience, 1 year UR experience or Case Management in a hospital or commercialinsurance setting. Must speak fluent English in order that the individual beable to take direction from management, physicians and external parties. Mustbe able to communicate adequately with patients, co-workers and physicians asnecessary, understand and follow safety guidelines and understand the AssociateHandbook and all hospital policies. Must have adequate computer skills.
Adequate conversationalEnglish is required in order that the individual be able to take direction frommanagement, understand how to complete job tasks, communicate adequately withpatients and co-workers as necessary, understand and follow safety guidelines,and understand the Associate Handbook and all hospital policies.
WorkingRelationships: The Utilization ReviewStaff is responsible to the Manager of Managed Care and does not supervise anyemployees. The position is in dailycommunication with the RN care coordinators, medical staff and payers,and must demonstrate effective communication skills.
Demonstrates a commitment toservice, organization values and professionalism through appropriateconduct and demeanor at all times
Adheres to and exhibits ourcore values: Reverence : Having a profound spirit of awe and respect for allcreation, shaping relationships to self, to one another and to God andacknowledging that we hold in trust all that has been given to us. Integrity : Moral wholeness, soundness, uprightness, honesty andsincerity as a basis of trustworthiness. Compassion : Feeling with others, being one with others in theirsorrows and joys, rooted in the sense of solidarity as members of thehuman community. Excellence : Outstanding achievement, merit, virtue; continuallysurpassing standards to achieve/maintain quality.
Maintains confidentiality andprotects sensitive data at all times
Adheres to organizational anddepartment specific safety standards and guidelines
Works collaboratively andsupports efforts of team members
Demonstrates exceptionalcustomer service and interacts effectively with physicians, patients,residents, visitors, staff and the broader health care community
Catholic Health Initiativesand its organizations are Equal Opportunity Employers
Primary Location KENTUCKY-LEXINGTON-SAINT JOSEPH HOSPITAL
Daily Schedule 8am
Scheduled Hours per 2-week Pay Period 0
Weekends Required Occasional
Req ID: 2018-R0162366
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.