Bachelor's Degree in Nursing
* Case Management certification by recognized certifying organization (i.e., NCQA, CCMC) preferred can obtain within 24 months of hire.
* Active nursing license in Alaska or other U.S. state required.
* Direct Hire must have applied for an Alaska nursing license at time of hire. Agency staff must have an active Alaska license.
* High school diploma or equivalent required.
Experience Required
* 8 years' clinical care or nursing experience, 3 years of which should be in chart review, risk management, or related quality service
Knowledge of
* Conducting and reviewing medical records for medical necessity, level of care, and public and private insurance reimbursement.
* Basic ICD-9 and CPT coding.
* Regulations as set forth by The Centers for Medicare Medicaid Services.
* Proficient in medical terminology, anatomy, physiology, and concepts of disease.
Skills in
* Providing effective nursing care, assessing patient situations and taking effective courses of action.
* Strong written and oral communication skills.
* Strong organizational skills.
Ability to
* Ability to communicate and collaborate effectively with providers, staff, and patients.
Additional Details:
Position Information:
Work Shift:OT 8/40
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us-
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Description
Pay Range:$ $64.18SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.
Working at SEARHC is more than a job, it's a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health, dental, and vision benefits, life insurance and long and short-term disability, and more.
* Key Essential Functions and Accountabilities of the Job
* Reviews patients' records and evaluates patient progress.
* Performs continuing review of the patient hospitalization to specifically monitor the necessity for and appropriateness of hospitalization, length of stay, and quality of care.
* Provides these UM and review functions to the Purchased/Referred Care Services program for SEARHC beneficiary patients admitted to other facilities.
* Obtains and reviews necessary medical reports and treatment plans as requested by regulatory agencies or payers.
* Reviews and validates physician orders, reports progress and unusual occurrences on patients.
* Works with the MEH leadership, clinical care team and physicians to ensure healthcare services are appropriate and cost-effective.
* Collaborates with physicians, MEH leadership, and the clinical care team to ensure adherence to the UM/CM/DCP plan.
* Reviews new hospital admissions to assess patient condition(s) and needs in order to develop personalized treatment plans.
* Provides appropriate or required information to patients and/or their families regarding their healthcare benefits.
* Reviews patient records and participate in interdisciplinary collaboration with professional staff.
* Ensures maintenance of the Utilization Review Plan collaboration with the Utilization review staff Medical Director (or designated provider).
* Facilitates educational programs and advises physicians and other departments of regulations affecting UM/CM/DCP.
* Directs the coordination of patient care departments, ensuring treatment plans are based on the need of the patient and meet criteria approved by the hospital and any regulatory or payer requirements.
* Ensures documentation supports the UM functions and communicates with payers within required timeframes.
* Reviews information, communicates results to claims adjusters, and enters billing information appropriate.
* Prepares information for notification letters providers, staff, and patients.
* Received and processes request for appeal of denials.
* Responds to complaints per UM review guidelines.
* Maintains utilization review and appeal logs.
* Supports clinical improvements activates of SEARHC by providing quality review.
* Performs tumor registry functions for SEARHC.
Other Functions
* Other duties as assigned.
* Education, Certifications, and Licenses Required
*
