MEDICAL REVIEW RN
Location: Rancho Cordova California
Description: Mercy Healthcare Sacramento is presently looking of MEDICAL REVIEW RN right now, this job will be placed in California. More complete informations about this job opportunity please read the description below. (
Job ID
:
1300016414
)
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UTILIZATION MANAGEMENT
About This Position
Position Summary:
The primary func! tion of this role is remote response to Dignity Health hospitals to conduct emergency department admission screening reviews. Through collaboration with the contracting emergency departments and physicians, the admission status determination service insures that patients are assigned to the appropriate admission status and level of care. To facilitate telephone interviews and document medical necessity strong communication skills are required. Use of the InterQual Criteria Set, Midas software and the ability to navigate various electronic medical record formats is required.
The role requires knowledge of RN scope of practice, current state requirements, CMS conditions of participation, EMTALA, The Patient Bill of Rights, AB1203 and other Federal or State regulatory agency requirements specific to utilization review and discharge planning.
This position requires the full understanding and active participation in fulfilling the Mission of the Organization. I! t is expected that the employee will demonstrate behavior cons! istent with the Core Values. The employee shall support the Organization’s strategic plan and the goals.
Qualifications:
Graduate of an accredited RN School of Nursing
Bachelor’s degree preferred.
Minimum of three years in acute care hospital experience required. One to two years case management experience preferred
Recent UR experience preferred
Broad knowledge of medical and allied health sciences
Demonstrated ability to measure screening criteria against the documented medical record
Excellent written and verbal communication skills
Current Registered Nurse (RN) License to practice professional nursing within the state employed.
Core Job Function:
Utilization Review
Consistently applies the utilization review process as required by the Code of Federal Regulations including the use of the Dignity Health designated criteria for primary review. Incorporates in! to the utilization review process the ability to access and interpret clinical information against the designated review criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial/performance benchmarks for the facility and Dignity Health.
Accountabilities:
Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required timeframes
Review every admission and observation order for appropriateness based on InterQual criteria within the required timeframes and follows the approved utilization review procedures if the patient status order is not c! onsistent with the medical necessity assessment.
Notifies admi! ssions office of errors/changes in patient data including changes in physician orders/incorrect admission status designation.
Documents insurance authorizations received in Midas.
Coordinates internal and external services to avoid under or over utilization of resources.
Indicates the working DRG in MIDAS and other tools.
Facilitates or participates in interdisciplinary team meetings.
Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned.
Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay.
Refers cases to Physician Advisor according to policy and documents the referral.
Initiates the appropriate letter (HINN: admission or continued stay, ABN) for any Medicare beneficiary if the outcome of the Physician Advisor! secondary review indicates that the patient does not meet inpatient admission/observation status or continued stay medical necessity criteria.
Completes, when assigned, the Dignity Health Care Management Rebill Log or other approved communication tools or processes related to billing appropriateness. The log communication includes PFS notification when the outcome of the Physician Advisor secondary review indicates that the patient does not meet admission medical necessity criteria or changes in patient status including the use of Condition Code 44.
All patients presenting to the hospital from ALL points of entry will be assessed for medical necessity, appropriate status and level of care by an RN Case Manager at or before the time of inpatient admission or placement into Outpatient Observation status; payer authorization documented when required
Points of entry management
Cross train and provide coverage as needed to GSSJSA transfer cen! ter.
UNIVERSAL EXPECTATIONS
1. Mission and Dignity He! alth Core Values
Employees will perform their job in a manner consistent with demonstrate the Dignity Health core values of excellence, collaboration, dignity, justice and stewardship.
Dignity â€" Demonstrates respect and empathy for each patient’s and family’s privacy and unique needs
Excellence â€" Strives to perform at a high level in order to provide excellence in patient care.
Collaboration â€" Participates in hospital and / or community-based programs to provide support to those in need.
Stewardship - Performs daily duties with a responsible utilization of patient, hospital, and community resources
Justice - Works to ensure support, safety, care, and well being for all patients, families and co-workers, regardless of race, religion, gender, social/economic status or ability.
2. Professionalism, Quality, Growth and Safety.
Employees will conduct their job functions in a manner consistent with t! heir professional licensure and will demonstrate willingness to learn, improve, grow and achieve.
Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
Effectively organizes work priorities.
Demonstrates compliance with facility and departmental safety and security policies and practices.
Educates hospital team members and physicians about the Case Manager role and scope of RN practice.
Supports the hospital quality, risk and performance improvement programs.
Keeps informed of local departmental policies and Dignity Health initiatives by attendance staff meetings and Dignity Health sponsored conference calls, meetings and events.
Demonstrates appropriate attendance per company policy and ensures that unscheduled absences do not exceed the Dignity Healt! h or facility standard.
Provides proper notification of absenc! es or tardiness within established standards.
Exhibits interpersonal, collaborative and team building qualities as well as awareness of one’s own behaviors and adjusts behavior and actions appropriately.
Adheres to all Dignity Health, Human Resources and Compliance Policies and Procedures.
About Us
Dignity Health
, headquartered in San Francisco, California, provides integrated, patient and family centered care. It is the fifth largest health system in the country with 10,000 physicians and 55,000 employees across Arizona, California, and Nevada. Through its network of more than 150 ancillary care sites and 40 acute care hospitals, Dignity Health is committed to delivering compassionate, high-quality, affordable health care services with special attention to the poor and underserved. In 2011, Dignity Health provided $1.4 billion in charity care, community benefit and unreimbursed patient care. For more information, please visit! our website at
www.dignityhealth.org
. Dignity Health is also on Facebook and Twitter.
Organization
:
Mercy Healthcare Sacramento
Primary Location
:
California-Greater Sacramento Service Area-Rancho Cordova-Mercy Healthcare Sacramento
Work Locations
:
Mercy Healthcare Sacramento
3400 Data Drive
Rancho Cordova
95670
Hours Per Pay Period
:
80
Shift
:
Night
Employment Type
:
Full Time
Work Schedule
:
12HOUR
Number of Openings
:
1
Area of Interest
:
Nursing - Registered Nurse
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Mercy Healthcare Sacramento.
If you interested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Sun, 10 Nov 2013 03:42:28 GMT