RN ULTILIZATION REVIEW FULL TIME DAYS AT THE HOSPITALS OF PROVIDENCE
- Job ID 1905022240
- Date posted 09/19/2019
- Facility THOP Market Shared Services
The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position integrates national standards for case management scope of services including:
Utilization Management services supporting medical necessity and denial prevention
Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
- Accurate medical necessity screening and submission for Physician Advisor review
- Securing and documenting authorization for services from payers
- Managing concurrent disputes
- Collaborating with payers, physicians, office staff and ancillary departments
- Timely, complete and concise documentation in the Tenet Case Management documentation system
- Maintenance of accurate patient demographic and insurance information
- Identification and documentation of potentially avoidable days
- Identification and reporting over and underutilization
Required: Two (2) years hospital acute or behavioral health patient care experience.
Preferred: One (1) year hospital acute or behavioral health case management.
Required: Active and valid RN license.
Preferred: Accredited Case Manager (ACM).
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.Tenet participates in the E-Verify program. Follow the link below for additional information.