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Utilization Review RN - Case Management - Part Time - Mishawaka

Company: Saint Joseph Health System
Location: Mishawaka
Posted on: June 14, 2019

Job Description:

Minimum: $29.17 - Maximum: $45.21 JOB SUMMARY To provide clinical review against standard criteria for the purpose of evaluating medical necessity, regardless of payor type and upon review, the utilization review coordinator provides feedback and assistance to other members of the care team in regard to the appropriate use of resources and timely follow-through of the care plan. JOB DUTIES 1.--Actively demonstrates the organization's mission and core values, and conducts oneself at all times in a manner consistent with these values. 2.--Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. 3.--Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care service or facility to comply with governmental and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, length of stay and discharge of patients. 4.--Reviews application for patient admission and approves admission or discusses case with Utilization Review Committee and/or individual supervisory staff for reviews and course of action when case fails to meet admissions, treatment, length of stay and/or discharge standards. 5.--Identifies utilization problems by: Examining the findings of related quality assurance activities; participating with clinical staff in the development and implementation of concurrent reviews focusing on the diagnoses, procedures and/or clinicians with identified or suspected utilization related problems; and reviewing results of patient care evaluation studies and reimbursement agency utilization reports. 6.--Plans, directs and coordinates activities of the various service components to insure compliance with the mandates of regulatory agencies. 7.--Facilitates and monitors discharge, recertification or transfers of patients as soon as level of care is no longer required or is appropriate. 8.--Reviews patient admission records to ascertain medical justification for admission; assures that admissions are to the appropriate service and level of care; reviews patient progress to ascertain need for continued services. Abstracts data from records and maintains statistics. 9.--Consults with reviewing agencies of fiscal intermediaries including but not limited to Medicare and private insurance companies, regarding the preparation and processing of documents for reimbursement for medical services. 10.--Reviews medical records and other documentation in response to denials or authorizations for reduced level of care or length of stay as received from reviewing agencies; notifies attending physicians, patients, hospital staff, and fiscal intermediaries when continued care cannot be certified. 11.--Provides information to medical and clinical staff regarding documentation required for reimbursements, program coverage and utilization review activities and processes. 12.--Compares medical records to established criteria and confers with medical, nursing, therapy and other professional staff to determine legitimacy of patient treatment, length of stay and/or discharge. 13.--Attends meeting of the Utilization Review Committee and submits reports as required; Participates in the development of a written plan that describes the Utilization Review Program and governs its operations. 14.--Assigns, directs and coordinates the work of subordinate personnel; trains and supervises professional, clerical and para-professional staff involved in Utilization Review support activities. 15.--Compiles information; keeps records, prepares or directs preparation of reports and correspondence. 16.--Performs other duties consistent with purpose of job as directed. JOB SPECIFICATIONS AND CORE COMPETENCIES Education: Graduate of an accredited RN program. Bachelor's Degree in Nursing preferred. Licensure: RN Indiana License. Experience: Two (2) years performing patient care duties as a Registered Nurse in an acute care hospital and two years of utilization review experience in an acute care hospital or professional review organization. Knowledge of, but not limited to: -----Medicare, Medicaid and other reviewing agency regulations; Hospital and home health care department functions, routines, policies and procedure; -----Clinical nursing principles and techniques, disease entities; current medical diagnoses, procedures, treatment modalities, equipment and supplies; basic principles of management and supervision; Other Job Requirements:-- Excellent communication skills both oral and written. Strong computers skills which would include full knowledge of office software. Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs.

Keywords: Saint Joseph Health System, Mishawaka , Utilization Review RN - Case Management - Part Time - Mishawaka, Executive , Mishawaka, Indiana

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