Remote Utilization Review RN – Nebraska

Job Overview

  • Clinical License RN
  • State(s) NE

Requisition ID 2022-253744

Employment Type Full Time

Department Care Management

Hours/Pay Period 80

Shift Day

Weekly Schedule 8-5

Remote No

Category  Case Management and Social Work

 

 

 

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Responsibilities

Work from home after training in Omaha

Responsible for the review of medical records for appropriate admission status and continued hospitalization.  Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking.  Collaborates with the Concurrent Denial RNs  to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Essential Key Job Responsibilities

  • Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.  Reviews include admission, concurrent and post discharge for appropriate status determination.
  • Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
  • Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
  • Ensures timely communication and follow upwith physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
  • Collaborates with facility RN Care Coordinators to ensure progression of care.
  • Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
  • Communicates the need for proper notifications and education in alignment with status changes.
  • Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.
  • Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.
  • Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.
  • Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
  1. Responsible for completing required education within established timeframes.
  2. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
  3. Participates regularly in performance improvement teams and programs as necessary.
  4. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
  5. Responsible for completing required education within established timeframes.
  6. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
  7. Performs other duties as assigned.

Qualifications

Minimum two (2) years of acute hospital clinical  experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience

Graduate of an accredited school of nursing (Bachelor’s Degree in Nursing (BSN)) or related healthcare field.

At least five (5) years of nursing experience.

RN license in the state(s) covered is required.

Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred

BLS required within 3 months of hiring if located within hospital

Proficient in application of clinical guidelines (MCG/InterQual) preferred

Knowledge of managed care and payer environment preferred

Knowledge of CMS standards and requirements.

 

 

 

 

Thanks for visiting!

The Remote Nurse is a large online community and Job Board specializing in Remote Telehealth Jobs for Nurses, Nurse Practitioners, and Physician Assistants.

Follow us!