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Form of work
SalaryOverview:
USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
Responsibilities:
Performs functions independently, according to policy and third party payor requirements, to include: quality reviews, prior authorizations, initial/admission reviews, continued stay reviews, discharge reviews, retrospective reviews, appeals as appropriate for denials, and case management reviews for DRG payors; analyzes medical record data to complete functions; collaborates with members of the healthcare team, patients, families, and managed care workers to formulate appropriate discharge plans and promote a safe and timely flow through inpatient setting; ensures optimal reimbursement from third party payors through appropriate implementation of Care Management functions; communicates with healthcare providers via telephone, in person, and email (i.e., discussion with physicians regarding plan of care, length of stay, and stay type); establishes and maintains a professional relationship with third party payor representatives; participates in interdisciplinary patient care meetings as assigned; utilizes a PC to access the Hospital Information System; enhances professional growth and development through participation in educational programs; completes annual education on nationally recognized level of care criteria; participates in all Care Management audit activities as assigned; orients new staff to the Care Management process as assigned; reports quality of care concerns discovered during Care Management functions to the Director; facilitates timely patient throughput through discharge planning commensurate with the care needs of the patient; evaluates chart documentation for completeness relative to current ICD requirements and communicates deficiencies; demonstrates proficiency in Early Periodic Screening Diagnosis and Treatment (EPSDT) by performing independently, according to regulatory requirements, the following functions as assigned: identification of patient eligibility, collection of data required to perform screening, performance of Inter-periodic Screening Components, and communication of screening findings to all related parties; maintains accurate and complete records both written and via personal computer; documents reviews according to hospital policy; completes/documents forms/requests from third party payors and regulatory parties; documents variances, discharge plans and EPSDT functions; utilizes proper body mechanics when moving equipment that is necessary to perform essential functions; communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone; adheres to current Infection Control and Safety Standards; responds to overhead pages; accesses and accurately maintains electronic and paper medical records; participates on committees as assigned; participates in Performance Improvement activities as assigned; regular and prompt attendance; ability to work schedule as defined and additional hours and call as needed; related duties as required.
Qualifications:
Graduation from an accredited school of nursing, two years professional nursing experience, and licensure with the state of Alabama as a Registered Nurse. Previous Utilization Review experience preferred.
