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Utilization Review Nurse at HCA Healthcare

Posted in Other 30+ days ago.

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Type: Full Time
Location: Henderson, Nevada





Job Description:

DESCRIPTION SHIFT: Work From Home

SCHEDULE: Full-time

Are you looking for a company that places integrity over their bottom line? Here at HCA, our everyday decisions are founded on compassion. Apply today and join a team that is dedicated to serving others in need.

You contribute to our success. Every role has an impact on our patients' lives and you have the opportunity to make a difference. We are looking for dedicated professional like you to be a part of our team. Join us in our efforts to better our community!

We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO medical, dental, flex spending, life, disability, tuition reimbursement, employee discount program, employee stock purchase program. We would love to talk to you about this fantastic opportunity.

Healthcare Corporation of America (HCA) is a community of 94,000 Registered Nurses and 38,000 active physicians. We have over 1,900 facilities ranging from hospitals, freestanding ER's, ambulatory surgery centers, and urgent care clinics. Our facility based staff continues to raise the bar in patient care. Ten HCA hospitals have been named in IBM Watson Health's top 100 best-performing hospitals based on patient satisfaction and operational data.

STATUS: Full Time

SCHEDULE: Work from Home

POSITION SUMMARY:

Provide clinical information to patient Insurance Plans according to the terms of the contract, receive authorization / certification for the stay, work concurrent denials, determine the correct patient status and communicate to the facilities, follow the X-Code process per HCA policy, maintain communication with the facility case managers, physicians and the Insurance Plans.

SPECIFIC ELEMENTS AND ESSENTIAL FUNCTIONS:

THIS POSITION WILL FOCUS ON INITIAL AND CONTINUED STAY UTILIZATION REVIEWS AND DENIALS MANAGEMENT. THIS MAY INCLUDE ASSESSMENT OF MEDICAL RECORDS FOR MEDICAL NECESSITY AND APPROPRIATENESS IN STATUS ASSIGNMENT AND/OR LEVEL OF CARE PROVIDED. A TEAM APPROACH WITH THE FACILITY CASE MANAGEMENT TEAM IS CRITICAL.

* Validate the patient's status is correct (Inpatient vs Outpatient) based on physician's order, take action to correct status if incorrect or no order is present. Document actions.

* Perform admission reviews, on in scope populations, utilizing InterQual within 24 hours of admission.

* Perform initial admission clinical summary reviews within 24 hours or per payor contract on payors with an authorization process.

* Perform continued stay InterQual reviews a minimum of every other day on in scope populations.

* Perform continued stay clinical summary reviews as per payor contract on payors with an authorization process.

* Escalate cases not meeting criteria to Division PA

* Review and manage concurrent denials per FWD Centralized Utilization Review policy

* Follow X-Code process as per HCA policy.

* Communicate with physicians regarding patient status, level of care. Medical necessity, utilization of resources, and denials.

* Communicate lack of medical necessity and/or responder criteria being met to the facility Case Manager.

* Review the Certification / Authorization report daily to determine deficiencies.

* Documentation to take place, per HCA and FWD guidelines, in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module.

· We are a family 270,000 strong! Our Talent Acquisition team is reviewing applications immediately. Highly qualified candidates will be promptly contacted by our hiring managers for interviews. Submit your resume today to join our community of caring!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

QUALIFICATIONS MINIMUM QUALIFICATIONS
EDUCATION:

* B.S. in Nursing, Business Administration or Healthcare Administration preferred or equivalent work experience.

EXPERIENCE:

* InterQual experience required, minimum of one year.

* Acute care hospital experience preferred.

* Third Party Payer and Denial Management experience a plus.

LICENSURE/CERTIFICATION:

* Registered Nurse (RN)

* Certification in Case Management preferred or is willing to pursue in the first year (or when eligible).

SPECIAL QUALIFICATIONS:

* Self-starter and independent worker. Excellent time management and problem solving-skills. Ability to communicate clearly, professionally and concisely. Excellent critical thinking skills. Strong organizational skills and able to proactively prioritize needs and effectively manage resources. Ability to work within a Team. Excellent written and oral communication skills along with excellent interpersonal skills. Position requires candidates with determined and assertive communication skills. Must pass annual InterQual competency testing.

TECHNICAL SKILLS:

* Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software).

HOURS OF WORK:

* Schedule flexible as per UR department needs, some weekends, after hours, and/or holiday work will be required.