Benefits:
- 401(k)
- Health insurance
- Paid time off
Summary:
The Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. The Utilization Management is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.
Duties and Responsibilities
- Pre-certification - performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual
- Ensures care delivered in fiscally responsible manner
- Reports exceptions and variances to Quality Committee and/or responsible staff
- Makes informed recommendations as to Level of Care, Length of Stay, and documentation for medical necessity is appropriate.
- Ensures payer requirements met to insure payment for services rendered. Assists in denial appeals as needed. Monitors insurance for payment/care trends and patterns and refers to appropriate staff
- Compiles, integrates information as needed
- Acts as liaison with providers, patients, families, payers, CMS and QIO
- Functions as a clinical resource for the multi-disciplinary care team in order to maximize quality of care while achieving effective medical cost management
- Maintains current and up to date knowledge of current Utilization strategies
- Reviews continued stays using nationally approved criteria
- Ensures payer requirements met for reimbursement
- Considers, addresses and coordinates needs outside of facility as needed
- Complies with payer requirements to maximize reimbursement for post discharge services and minimize cost to patient
- Complies with federal and state regulations concerning financial interest disclosure and choice of provider
- Compiles statistics and monitors for trends.
- Attend and report as required at Quality and MEC meetings for any Utilization Management needs
- Write, review, update departmental Policies and Procedures
- Represent UR at departmental meetings and situations, including Quality Meeting, Medical Staff and MEC meetings as needed
- Assists for third party appeals and communications
- Work closely with Business Office, Revenue Cycle Analyst and HIM to facilitate reimbursement process
- Work closely with Quality Management/Case Managers to ensure quality care is extended to each patient and family
- Maintain current and up-to-date knowledge of relevant case management and utilization management policies, laws and practices
- Performs other duties as assigned
Education and Experience:
- Associate or Bachelor's Degree in Nursing. Current state RN licensure
- 5 years Utilization Review experience preferred
- Experience in a fast paced environment; orthopedic and spine experience strongly recommended.
License, Certificate or Registration:
- Current Louisiana RN State Licensure
- BLS Required
Physical Requirement:
- Able to maintain moderate standing, sitting, and bending.
- Physically able to perform CPR.
- Must be able to lift 15 lbs.
Benefits:
- Seven paid holidays
- Sick and vacation after waiting period
- Health, vision, and dental coverage
- Employer paid life insurance and long-term disability
- 401k with employer contribution
- Pay in Lieu of Benefits option offered
Specialists Hospital Shreveport is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
Specialists Hospital Shreveport provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Specialists Hospital Shreveport, LLC
Specialists Hospital is proudly physician owned and is actively in involved in the Physician Owned Hospitals of America (http://www.physicianhospitals.org/) and the Louisiana Physician Owned Hospital Association (http://www.lhaonline.org/) . Specialists Hospital Shreveport located in Shreveport, Louisiana offers you state of the art treatment in orthopedic and spine surgery- all in a unique, patient-centered environment that is close to home. Whether you are undergoing an outpatient or inpatient procedure, the physicians and staff at Specialists are committed to providing you compassionate and expert care while allowing for a seamless transition from hospital to home. Specialists Hospital Shreveport is the only hospital in Louisiana that focuses solely on orthopedic, spine and spinal neurosurgery.
Company Website: www.specialistshospitalshreveport.com
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