Description
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
Summary: Responsible for collaboration with members of interdisciplinary health care team (physicians, other health care professionals, payers, etc.) to identify appropriate utilization of hospital resources and to ensure timely reimbursement for services rendered; including communication between hospital and third-party payers to ensure hospital services will be reimbursed and denials minimized. Utilizes established criteria to confirm medical necessity for admission to the hospital, continued stay, and use of other hospital services in accordance with Utilization Management Plan, Conditions of participation (CoP) and other federal and third-party payer regulations and guidelines. Collaborates with the health care team to ensure efficient throughput from hospital admission through discharge and to the appropriate post-acute setting.
Responsibilities:
1. Constantly maintains an environment of safety to patients, self, and others. As well as compliance to established internal and external policies and procedures and practice standards.2. Functions in a team-like fashion utilizing approved evidenced-based criteria for the determination of the appropriateness of medical necessity reviews (i.e. - observation/outpatient, inpatient) within 24 hours of patient's admission to the acute care setting and for continued stay in the hospital until the patient is discharged.
3. Actively participates in the identification and obtaining appropriate patient status orders by communicating with the patient's attending physician or surgeon in order to ensure timely billing and reduce the risk of reimbursement denials.
4. Communicates with third-party payers to ensure authorization for services is obtained and completes necessary appeals for concurrent or discharged patients.
5. Consults with Physician Advisors to assist with the determination of appropriate status and follow up regarding medical necessity for admission to and continued stay in the acute care setting.
Education Requirements:
- Associate's in nursing (Graduate of an approved nursing program)
- Bachelor's of Science in Nursing (BSN)
Licensure/Certification Requirements:
- RN (valid North Carolina license without sanctions)
Preferred Certifications & Licensures
- Utilization Review or other applicable certification
Professional Experience Requirements:
- 3 - 5 years of experience in healthcare/medical - acute care (acute hospital setting)
- 0-2 healthcare/medical - -utilization review (or other healthcare-related experience)
- 3-5 years of recent acute hospital experience with relevant experience and working knowledge in Utilization Review, including managed care/commercial payers and governmental regulatory requirements.
Other information:
Legal Employer: Nash Hospitals
Entity: Nash UNC Health Care
Organization Unit: NGH Case Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: NASH HC
Exempt From Overtime: Exempt: No
