What are the responsibilities and job description for the Coordination Of Care- Utilization Review Management, Full Time Days position at Cape Fear Valley Health?
20,000 SIGN ON BONUS AND RELOCATION ELIGIBILITY
Facility
Cape Fear Valley Medical Center
Location
Fayetteville, North Carolina
Department
Coordination of Care
Job Family
Nursing
Work Shift
Days (United States of America)
Summary
The Utilization Review RN is responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers is conducted to determine medical necessity for admission. Partners with physicians to establish appropriate status and level of care requirements. Works with the physician, advanced practice provider, interdisciplinary team, and other member of the Case Management team to facilitate clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost-effective manner. Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Performs continued stay reviews and ensure appropriate and cost-effective healthcare services to patients. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner.Profession Certification in Case Management (CCM or ACM) preferred. Minimum three to five years’ experience in Acute Care setting preferred. Medical/Surgical and/or ICU experience preferred. Case Management Experience preferred. Additional one year in managed care claims/reimbursement or other healthcare field preferred. Strong clinical background. Knowledge of professional nursing principles, clinical processes and clinical interventions. Excellent interpersonal communication and negotiation skills. Able to communicate effectively and work with people of all social, economic, and cultural background. Self-motivated, proven written, telephonic and electronic communication skills, assertive and persuasive in interactions with customers, peers, management and core staff served. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Understanding of criteria and measurement outcomes. Knowledge of third party payor requirements including managed care, reimbursement and utilization management. Proficiency with various computer programs, to include Microsoft Office, Midas, Allscripts, ValleyLink, eHIM, Teletracking, EMSTAT and SMS. Skills necessary to build credible and effective relationships with physician leadership, the internal and external customer. Flexible, open-minded and adaptable to change. Models positive change. Ability to demonstrate respect and team building. Able to prioritize and process multiple tasks, responsibilities and work projects, demonstrating strong organizational and time management skills. Demonstrated ability to analyze related information, plan effective actions and follow through reliably to meet expectations. Ability to work and promote interdependence demonstrated in actions resulting in sound judgment with interactions with physicians, peers, patients and /or designee, payors, support service personnel. Ability to work collaboratively with department staff, physicians and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain or exceed Joint Commission standards and state mandates as they apply to the department operations.Some light carrying and lifting may be required. Occasional walking may be required to access all areas of the Medical Center. Ability to effectively communicate orally to patients, family members, personnel and physicians. Near visual acuity to proofread hand or typewritten materials. Manual ability to use telephones and computer keyboard. Position involves sitting for extended periods of time performing data entry into a computer.
Required Licenses And Certifications
RN - Board Of Nursing
Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
Facility
Cape Fear Valley Medical Center
Location
Fayetteville, North Carolina
Department
Coordination of Care
Job Family
Nursing
Work Shift
Days (United States of America)
Summary
The Utilization Review RN is responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers is conducted to determine medical necessity for admission. Partners with physicians to establish appropriate status and level of care requirements. Works with the physician, advanced practice provider, interdisciplinary team, and other member of the Case Management team to facilitate clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost-effective manner. Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Performs continued stay reviews and ensure appropriate and cost-effective healthcare services to patients. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner.Profession Certification in Case Management (CCM or ACM) preferred. Minimum three to five years’ experience in Acute Care setting preferred. Medical/Surgical and/or ICU experience preferred. Case Management Experience preferred. Additional one year in managed care claims/reimbursement or other healthcare field preferred. Strong clinical background. Knowledge of professional nursing principles, clinical processes and clinical interventions. Excellent interpersonal communication and negotiation skills. Able to communicate effectively and work with people of all social, economic, and cultural background. Self-motivated, proven written, telephonic and electronic communication skills, assertive and persuasive in interactions with customers, peers, management and core staff served. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Understanding of criteria and measurement outcomes. Knowledge of third party payor requirements including managed care, reimbursement and utilization management. Proficiency with various computer programs, to include Microsoft Office, Midas, Allscripts, ValleyLink, eHIM, Teletracking, EMSTAT and SMS. Skills necessary to build credible and effective relationships with physician leadership, the internal and external customer. Flexible, open-minded and adaptable to change. Models positive change. Ability to demonstrate respect and team building. Able to prioritize and process multiple tasks, responsibilities and work projects, demonstrating strong organizational and time management skills. Demonstrated ability to analyze related information, plan effective actions and follow through reliably to meet expectations. Ability to work and promote interdependence demonstrated in actions resulting in sound judgment with interactions with physicians, peers, patients and /or designee, payors, support service personnel. Ability to work collaboratively with department staff, physicians and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain or exceed Joint Commission standards and state mandates as they apply to the department operations.Some light carrying and lifting may be required. Occasional walking may be required to access all areas of the Medical Center. Ability to effectively communicate orally to patients, family members, personnel and physicians. Near visual acuity to proofread hand or typewritten materials. Manual ability to use telephones and computer keyboard. Position involves sitting for extended periods of time performing data entry into a computer.
Required Licenses And Certifications
RN - Board Of Nursing
Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
