Job Summary:
Interacts with the Interdisciplinary staff to complete the process of utilization management.
Education:
Required:
Graduate from an accredited school of Nursing.
Preferred:
Experience:
Required:
Broad clinical experience required with prior experience preferred in utilization management. Knowledge of managed care practices preferred with minimum of five years experience and evidence of clinical knowledge and familiarity with regulatory and insurance reimbursement issues. Broad clinical experience.
Preferred:
Position Requirement(s): License/Certification/Registration
Required:
Current license to practice nursing in the State of Tennessee.
The Nurse Licensure Compact will not change how to obtain or renew a Tennessee license. However, the Tennessee nursing license will be a single state license for Tennessee Residents or non-compact state residents. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.
Preferred:
Prior experience in utilization management. Knowledge of managed care practices with minimum of three years experience and evidence of clinical knowledge and familiarity with regulatory and insurance reimbursement issues.
Department Position Summary:
Responsible for initial and concurrent review of the patient's record and obtaining information obtained from physicians during a patient's encounter to determine medical necessity of the admission, observation and/or procedures and continued length of stay. Additionally, responsible for observation management and capturing of avoidable days. Participates in the gathering/reporting of date for performance improvement activities. Takes responsibility for department and organization objectives.