What are the responsibilities and job description for the Utilization Review RN position at Mercy Healthcare?
Overview
Dignity Health one of the nation’s largest health care systems is a 22-state network of more than 9000 physicians 63000 employees and 400 care centers including hospitals urgent and occupational care imaging and surgery centers home health and primary care clinics. Headquartered in San Francisco Dignity Health is dedicated to providing compassionate high-quality and affordable patient-centered care with special attention to the poor and underserved. For more information please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.
Responsibilities
Responsible for Quality Assurance/Departmental revenue audits. This person will be responsible for a variety of tasks including daily review of all necessary Medical records for appropriate documentation as it relates to acuity/charges and CPT level description, reconcile medical record log, and provide ongoing feedback to the department manager on any documentation deficiencies and revenue loss. Previous patient care experience required. High school graduate or equivalent required.
Qualifications
Pay Range
$49.10 - $71.19 /hour
Dignity Health one of the nation’s largest health care systems is a 22-state network of more than 9000 physicians 63000 employees and 400 care centers including hospitals urgent and occupational care imaging and surgery centers home health and primary care clinics. Headquartered in San Francisco Dignity Health is dedicated to providing compassionate high-quality and affordable patient-centered care with special attention to the poor and underserved. For more information please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.
Responsibilities
Responsible for Quality Assurance/Departmental revenue audits. This person will be responsible for a variety of tasks including daily review of all necessary Medical records for appropriate documentation as it relates to acuity/charges and CPT level description, reconcile medical record log, and provide ongoing feedback to the department manager on any documentation deficiencies and revenue loss. Previous patient care experience required. High school graduate or equivalent required.
- Reviews cases that have been called into DH Transfer Center for repatriation and identify opportunities around Services Not Available, Unstable Cases, Physician Refusal, etc.
- Serves as liaison for Letter of Agreement (LOA) requests from affiliated IPA’s to DH, and facilitates the necessary clinical data (SBAR form) to hospital leadership in order execute these Letters of Agreement
- Actively engage with DH affiliated IPA’s around opportunities to redirect LOA requests in order to keep patients within DH network.
- Participates in daily rounds, Quarterly Joint Operations Meetings, and monthly clinical meetings with DH affiliated IPA’s to discuss opportunities around patient utilization
- Provide daily/weekly/monthly OON reports/updates to Director, Clinical Partnerships and others as required for analysis at Purchased Services Committee, Steering Committee and other utilization management committees as needed.
- And various other responsibilities
Qualifications
- California RN License required.
- Fire Safety card required.
- Five years experience in utilization review and discharge planning, case management and managed care.
- JCAHO and State and Federal Regulations. Coding, documentation, DRG’s. Case Management models and standards.
- Nursing theory and practice standards.
- Research models.
- Continuous quality improvement methods.
- Knowledge of reimbursement under Medicare, MediCal and private insurance, Capitation including Medical group/physician implication.
- Case management of capitated at-risk patients.
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Must be computer literate.
- Case Mgmnt Cert Preferred.
Pay Range
$49.10 - $71.19 /hour
Salary : $49 - $71