RN - Utilization Reviewer - Coordinated Care - PT - Remote

Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: • Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. • You must meet all of the job requirements at the time of submitting the application. • You can only apply one time to a job requisition. • Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. • Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID: R00046700 Job Category: Nursing Organization: Utilization Review Location/s: Main Campus Jackson Job Title: RN - Utilization Reviewer - Coordinated Care - PT - Remote Job Summary: Accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the um process to the appropriate manager. To perform job duties in accordance with the medical center's purpose. Education & Experience Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management. InterQual experience preferred. CERTIFICATIONS, LICENSES OR REGISTRATION REQUIRED: Valid RN license. CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred. Knowledge, Skills & Abilities Knowledge of the aspects of utilization review. Excellent interpersonal verbal and written communication and negotiation skills. Skills in the use of personal computers and related software applications. Ability to gather data, compile information, and prepare reports. Ability to identify process improvements. Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement. Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. Demonstrate commitment to the organIzation's mission and the behavioral expectations in all interactions and in performing all job duties. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and commitment to continuous quality improvement (CQI) process. Independent, focused and follow written instructions. Ability to use medical necessity guidelines with minimal supervision. Equipped to work remotely to include hardware with high speed internet via cable and Windows 10 RESPONSIBILITIES: • Performs all aspects of prospective, concurrent, retrospective and denials review for individual cases to include benefit coverage issues, medical necessity appropriate level of care (setting) and mandated services. • Assists in the collection and reporting of financial indicators including case mix, los, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction. Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by administrator - resource management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, care transitions and care coordination). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. • Applies approved clinical appr...