This positions is for a Full Time Registered Nurse in Utilization Review at Flaget Memorial Hospital in Bardstown, KY.
Job Summary / Job Purpose Works collaboratively with physicians, staff and other health care professionals within his/her Division to review and monitor members' utilization of health careservices with the goal of maintaining high quality cost effective care. The role includes providing the clinical and utilization expertise necessary to evaluate theappropriateness and efficiency of medical services and procedures. This includes providing referral authorization, concurrent review, appropriate referral to case management, and high dollar claims review. The Utilization Management RN is an integral member of the health care team as well as the Divisional CareManagement team. Collaborates with the Divisional Care Management team on system-wide quality improvement/performance improvement initiatives.
- Performs initial, concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.
- Ensures appropriate placement and monitors level and quality of care.
- Addresses care issues with Manager of Care Management, PhysicianAdvisor and Chief Medical Officer/Medical Director as appropriate
- Coordinates identification and reporting of potential high dollar/utilizationcases to reinsurer and finance department for appropriate reserveallocation.
- Consults with physicians, health care providers and outside agenciesregarding continued care/treatment or hospitalization
- Identifies and recommends opportunities for cost savings and improving thequality of care across the continuum.
- Review per diem patients daily for medical necessity to ensurereimbursement
- Responsible for the early identification and assessment of members forpotential inclusion in a comprehensive care management program. Refersmembers for care management accordingly.
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities.
- Reviews any service denials and gathers necessary supportingdocumentation from chart audits and follows up according to procedures.
- Assists in the identification and reporting of Potential Quality of Careconcerns.
- Responsible for assuring these issues are reported to the Care Management Manager.
- Provides backup for RN Care Manager.
- Work as an interdisciplinary team member within Divisional CareManagement departments.
- Clarifies health plan medical benefits, policies and procedures for members,physicians, medical office staff, contract providers, and outside agencies.
Position Type: Regular
Scheduled Hours per 2 week Pay Period: 72
Primary Location: KY > BARDSTOWN > FLAGET MEMORIAL HOSP
Your time at work should be fulfilling. Rewarding. Inspiring. That's what you'll find when you join one of our non-profit CHI facilities across the nation. You'll find challenging, rewarding work every day alongside people who have as much compassion as you. Join us and together we'll create healthier, stronger communities. Imagine your career at Catholic Health Initiatives!
As a Registered Nurse, you will be responsible for delivering the highest quality patient care according to the specific orders of each patient's individual physician. This will involve, utilizing your knowledge and skills to educate patients and their families on prevention and healthy habits.
Additional responsibilities for this health care role include:
- Monitoring patients' conditions and assessing their needs
- Collaborating with physicians and nurses to devise individualized care plans for patients
- Administering patients' medications and providing treatments according to physicians' orders
- Fostering a supportive and compassionate environment to care for patients and their families
We are looking for a responsible and compassionate Registered Nurse with top-notch clinical skills, a caring attitude, and the ability to work independently with minimal supervision. It is also important to display excellent verbal and written communication and interpersonal skills as well as the ability to effectively educate patients and their families on the in-home healthcare process.
Additional requirements for this role include:
- Current Registered Nurse (RN) license that allows you to practice in our state
- Graduate of an accredited nursing program
- Experience as a Registered Nurse preferred
- Basic Life Support (BLS) required
- Specialty certification (ex: CCRN, CNOR, CEN) preferred
- Additional certification or licensure may be required for some specialty areas
Join us at Catholic Health Initiatives, and become a part of our faith-based health system. Additional Information
- Requisition ID: 2019-R0236948
- Schedule: Full-time
- Shift: Day Job
- Market: CHI Saint Joseph Health
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