Utilization Review Registered Nurse - Work From Home

Company: HCA
Location: El Paso
Posted on: December 4, 2019

Job Description:

Description SHIFT: No WeekendsSCHEDULE: Full-timeUtilization Review Registered NurseWork from Home Position (Not required to live in El Paso)Must have a current RN license in good standingFull-Time, Monday - FridayWe offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO medical, dental, flex spending, life, disability, tuition reimbursement, employee discount program, employee stock purchase program and student loan repayment. We would love to talk to you about this fantastic opportunity_____________________________________________POSITION SUMMARYThe Utilization Review Nurse (URN) functions as the primary liaison between all third-party payers and the Case Management department. - -The URN -performs activities focused on assessing and communicating medical necessity on patient accounts requiring certification/authorization. The Utilization Review Nurse will perform clinical reviews on both inpatient and outpatient accounts using approved clinical criteria to evaluate medical necessity, admission status, level of care assignments, and discharge needs. - -The URN will -communicate required clinical information for the purpose of obtaining certification and approval for payment for all applicable outpatient observation stays, inpatient admissions and continued stay days. - -The URN will communicate and document all payer contacts using the established Case Management process. - -The URN works collaboratively with all payers, as well as, Case Management staff, Physician Advisor(s), physicians, healthcare team members, Patient Access Department, Central Verification Office and other key departments regarding the payer certification process to ensure authorization is received for all services provided. - -ESSENTIAL JOB RESPONSIBILITIES -Serves as the primary contact for all payors regarding utilization review and management issues.Performs concurrent payor reviews for medical appropriateness for patients placed in outpatient observation or in an inpatient setting according to payor guidelines, rules and regulations.Communicates proactively and cooperatively with Patient Access, Patient Account Services (PAS) and Central Verification Office (CVO) personnel to ensure proper pre-certification and consistency of admissions status designation between physician order and EMR.Collaborates with the Case Manager, Social Worker, attending physician, and other healthcare team members to ensure medical appropriateness criteria, - -to develop an action plan to avert reductions in care or denials and to obtain all payor information that - influence discharge planning activities.Provides all required clinical information to the payor according to the payor's timeframe standards throughout the hospitalization to obtain certification approval for all services provided.Maintains a collaborative working relationship with the payor's utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, etc. as needed.Refers all cases that are denied by the payor to the Concurrent Appeal Nurse or Physician Advisor.Establishes and maintains professional, collaborative working relationships with the Business Office Registration Department, Revenue Cycle Department and other key departments to facilitate processes to ensure timely and appropriate reimbursement for services provided. -Initiates the payor appeal process for all concurrent denials following the department guidelines for documentation and escalation. -Participates in coordinating on-going education for Case Management staff regarding government and payor regulatory and outcomes.Maintains productivity and meets all UR performance standards according to department policies and procedures.Serves as an educational resource for other Case Management staff, other internal departments, physicians, nursing staff and others concerning utilization management strategies essential in meeting the organization's quality, utilization, financial and customer satisfaction objectives. -Participates in process performance improvement activities related to utilization management. -Attends education sessions each year for internal and external customers regarding utilization management.Qualifications POSITION QUALIFICATIONS (REQUIRED) - - -RN with current state licensure -Two years of experience in case management, utilization management or related fieldCertification in Case Management, Nursing, or Utilization Review preferredAcute care hospital experience, preferredKnowledge of InterQual or related evidenced based criteria setsFamiliar with Joint Commission, State and Federal standards/requirements. -Knowledgeable about third party payer source criteria of medical necessity.Organized and able to meet deadlines consistently.Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing. -EXPERIENCE (REQUIRED)Two years of experience in case management, utilization management or related field - -KNOWLEDGE, SKILLS AND ABILITIESComputer literacy and familiarity with the operation of basic office equipment.Strong analytical, organizational and time management and computer skills.Excellent interpersonal communication and negotiation skills.Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients and families.Ability to communicate effectively with patients, clinical and administrative staff, and outside entities.Ability to interpret, adapt and apply guidelines and policies and procedures. -Ability to multi-task and deal with complex assignments on a frequent basisAbility to present in a group settingBroad-based clinical knowledge and understanding of pathology/physiology of disease processes -Perform all functions of the job with accuracy, attention to detail and within established time framesMeet attendance and punctuality standardsDemonstrate professional courtesy to others and maintain confidentiality - -LICENSE/CERTIFICATIONRequired: -Current RN license in the state of Texas or compact stateNotice Our Company's recruiters are here to help unlock the next possibility within your career and we take your candidate experience very seriously. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Gmail or Yahoo Mail. If you feel suspicious of a job posting or job-related email, let us know by clicking -here.
For questions about your job application or this site please contact HCAhrAnswers at 1-844-422-5627 option 1.

Keywords: HCA, El Paso , Utilization Review Registered Nurse - Work From Home, Healthcare , El Paso, Texas