- Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
- Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs.
- Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate.
- Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care.
- Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity.
- Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission.
- Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team.
- Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.
- Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.
- Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations.
- Performs other duties as assigned.
- Valid RN license in State of Maryland required and
- Bachelor's degree in Nursing preferred
- Clinical experience in acute care setting required and
- Experience with interqual and millimen preferred
- CCM - Certified Case Manager CCM preferred and
- ACMA preferred
- Verbal and written communication skills.
- Basic computer skills.
- Diagnostic and problem-solving skills.
- Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
- Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
- Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
- More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
RN Utilization Coordinator, FT Days, MedStar Union Memorial Hospital - Baltimore, United States - MEDSTAR HEALTH
Description
General Summary of Position
Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly.
Primary Duties and Responsibilities
Minimum Qualifications
Education
Experience
Licenses and Certifications
Knowledge, Skills, and Abilities
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.