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Job Description Summary

The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The Utilization Review case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction.

Job Description

Essential Functions

• Performs admissions and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective.
• Performs precertification on procedures ordered while patients are hospitalized.
• Issues required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized.
• Issues notifications of non-coverage letters to patients if received during hospital stay.
• Documents clear billing notes into the Electronic Medical Record (EMR) payer communications navigator to avoid billing denials.
• Performs medical necessity denial appeals.
• Maintains a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service.
• Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety

Supervised Positions

• None

Qualifications

Minimum Education Required

• Associates degree in Nursing
• Current Registered Nurse license in the State of Alabama

Minimum Education Preferred

• Bachelor’s degree or higher in Nursing

Minimum Experience Required

• Two (2) years acute care experience
• Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire

Minimum Experience Preferred

• Three (3) years acute care experience
• One (1) year utilization review experience

Required Knowledge/ Skills/ Abilities

• Maintain current licensure in the State of Alabama
• Demonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of Nursing
• Ability to quickly adapt to changing circumstances in fast-paced environment
• Actively accepts, understands, and practices appropriate standards of nursing practice.
• Must demonstrate basic knowledge of discharge planning needs
• Demonstrates advanced computer skills (ability to generate reports, graph trends).
• Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs.
• Ability to prioritize work and meet deadlines.
• Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
• Ability to develop leadership skills and to serve as a role model for clinical staff.
• Ability to lead and actively participate in multidisciplinary teams.
• Ability to work independently within a team structure.
• Demonstrates responsibility for educational requirements as evidenced by reading all assigned related references, and attending all required educational meetings, or webinars, and completing annual Symplr requirements.
• Demonstrates commitment to organizations five (5) priorities and Six Ground Rules
• Person in this position is required to understand, agree upon and follow our Six Ground Rules:
  • No excuses.
  • We are a team.
  • Bring up your ideas.
  • Poor performance will be addressed.
  • ‘That’s not my job’ is not acceptable
  • Manage Up.

Shift

Day

Shift Details

8:00 am - 4:30 pm

FTE

1

Type

Regular

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Equal Employment Employer

Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.