Description
POSITIONSUMMARY : Registered Nurse uses approvedscreening criteria (MCG® / CMS Inpatient List) to determine themedical necessity of a requested hospitalization and theappropriate level of care for that patient.
Actively involved inthe continued management of patient status / LOC. Providesconsultative role as utilization management nurse to clinical andnon-clinical departments.
Documents objectivefindings against approved indicators. Assists withretrospective reviews and medical necessity denials percommunication with third party payors.
Follows UR policiesand procedures and assists with continually improving the qualityand effectiveness of the utilization management program atCSVRMC.
Requirements
EDUCATION : Graduate of an approved school of nursing, BSNpreferred.
CERTIFICATION / LICENSES : Current licensure as an RN in New Mexico mandatory.
SKILLS :
- Excellent reading, writing, and editing skillsin English.
- Strong organizationalskills.
- Knowledge of or ability to learn MCG®for determining criteria.
- Ability toeffectively evaluate physician orders and medicalrecords.
- Competent computer skills for wordprocessing, data collection, and retrieval.
- Ability to analyze and create reports.
EXPERIENCE : Minimum of five years of experience in a health care setting, ofwhich a minimum of two years has been spent in an acute caresetting.
Experience with utilization management, knowledge ofMCG ® / criteria, managed care language, and CMS rules andregulations preferred.
NATURE OFSUPERVISION :
Responsible to : Manager of Case Management
ENVIRONMENT : Blood borne Pathogens : A
Office setting. Rotatingshifts and weekends when necessary. Must be able to adjust tofrequently changing workloads and frequent interruptions.
PHYSICALREQUIREMENTS :
Ability to movearound the hospital to all units / departments for about 10% of theday, in office 90% of the day. Requires close work, goodvision, dexterity to write as well as to use computer keyboard.
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Follows UR policiesand procedures and assists with continually improving the qualityand effectiveness of the utilization management program atCSVRMC. Experience with utilization management, knowledge ofMCG ®/ criteria, managed care language, and CMS rules andregulations preferred. Actively involved ...
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Provides consultative role as utilization management nurse to clinical and non-clinical departments. Follows UR policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC. Experience with utilization management, knowle...
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Follows UR policiesand procedures and assists with continually improving the qualityand effectiveness of the utilization management program atCSVRMC. Experience with utilization management, knowledge ofMCG ®/ criteria, managed care language, and CMS rules andregulations preferred. Actively involved ...
Utilization Review Coordinator / Case Management / PRN
Provides consultative role as utilization management nurse to clinical and non-clinical departments. Follows UR policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC. Experience with utilization management, knowle...
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