Utilization Review Coordinator

Job ID: 114380
Discipline: Nursing
Specialty: Registered Nurse
Sub Specialty: Case Management/Utilization Review
Date Posted: August 04, 2020
Address: 262 DANNY THOMAS PL. 318
Location: Memphis, TN 38105
Start Date: August 19, 2020
Employment Type: Per Diem
Pay Rate: Call for details
Company: Nursefinders

Job Description & Requirements



JOB RESPONSIBILITIES:

  1. Actively supports and incorporates the mission and core values of St. Jude into daily activities.  Treats all others with respect and demonstrates excellence and compassion in daily work and relationships with others.
 
  1. Maintains confidentiality of all information related to patients, medical staff, employees and all other information.  Adheres to HIPAA guidelines when sharing and receiving clinical information.
               
  1. Obtains pre-certification, re-certification, and retrospective approvals for inpatient stays and outpatient services performed at St. Jude.
  1. Monitors the scheduling system, inpatient census and the MILLI-PM system and its reports daily for patients whose insurance, Medicaid or other payor requires certification/authorization for inpatient stays or outpatient procedures.
  2. Integrates clinical knowledge with billing knowledge to gather applicable clinical information and communicates to the payor certification representatives as needed to receive approvals and extensions in a timely manner.
  3. Pursues and obtains letters of medical necessity from St. Jude physicians in support of payor pre-certification requirements.  Coordinates Peer to Peer review activities with St. Jude physicians as needed to obtain approval of services.
  4. Uses fax, phone, e-mail or online applications as provided by insurance companies to request and obtain authorizations for inpatient and outpatient services.
  5. Documents certification, re-certification, denial and pending information according to departmental policy and procedure.
  6. Communicates with other departments such as Managed Care, Patient Accounts, Outside Professional Services, Professional Services, Insurance Verification, Patient Registration, and Attending Physician  as needed
  7. Reviews medical records for medical necessity of admission, level of care, and length of stay for hospitalized patients using InterQual guidelines and documents in Milli PM and InterQual record.
  8. Coordinates the transition of patients to and from the BMT service as needed with the BMT URCs.
  9. Performs Quality Assurance activities as required by management. 
 
  1. In addition to the above UR activities, the Bone Marrow/Stem Cell Utilization Review Coordinator obtains pre-evaluation and authorizations for bone marrow transplants ("BMTs").
  1. Attends weekly BMT meetings to identify potential transplant cases.  Monitors the BMT Report, the IP census, and outpatient reports for scheduled services on insured transplant patients.   
  2. Notifies payer once the patient is tentatively identified or definitely scheduled for a transplant.  Determines what information is needed by the payer and initiates BMT records. 
  3. Gathers and provides clinical information to the insurance company transplant representatives and transplant networks as needed.  Such information may include but is not limited to, medical records, letter of medical necessity, etc.
  4. Maintains relationship with BMT staff and requests assistance as needed to obtain authorization. 
  5. Maintains separate files throughout the process documenting authorization request activities, approvals, or denials.  Documents pertinent information in Milli PM . 

  1. Maintain relationship with the dedicated transplant biller and review contracts to assure payment of transplant services.
  2. Follows patient throughout the transplant process until transitioned back to regular service.
 
  1. Performs other duties as assigned by the Utilization Review Supervisor or Manager to meet the goals and objectives of the UR department and hospital.
 
  1.  Maintains regular and predictable attendance.


EDUCATION AND/OR TRAINING:
Graduate of an accredited RN program. 
Bachelors' Degree in Nursing or a related area preferred.

EXPERIENCE:
Three (3) years related medical experience. 
Six (6) months experience in a hospital environment required.
Utilization review experience preferred. 
Experience with InterQual guidelines and Cerner systems preferred.

LICENSURE, REGISTRATION AND/OR CERTIFICATION REQUIRED BY LAW:
(LC:RN-TN) Must possess a current Tennessee State Board of Nursing license if primary residence is Tennessee or a Nurse Licensure non-Compact state.
(LC:RN-MISS, RN_ARK or RN-KY) Must possess a current State Board of Nursing license in the state of primary residence if the state is a Nurse Licensure Compact state.

LICENSURE, REGISTRATION AND/OR CERTIFICATION REQUIRED BY SJCRH ONLY:
Certified Case Manager preferred


SPECIAL SKILLS, KNOWLEDGE AND ABILITIES:
  1. Self-starter with ability to motivate others. 
  2. Data management in the quality improvement arena. 
  3. Demonstrated ability to interact with business and clinical personnel regarding patient demographic, payor and referral diagnosis information. 
  4. Knowledge of medical terminology and Personal Computer applications with Microsoft software in a Windows environment is required. 
  5. Ability to use productivity and performance tools (CQI). 
  6. Requires knowledge of authorization and insurance verification. 
  7. Ability to prioritize and delegate in response to multiple changing demands. 
  8. Strong written and oral communications. 
  9. Knowledge of online computer applications. 
  10. Excellent customer service skills.  Effective problem solving skills. 
  11. Understands the impact of accounts receivable, cash flow, and utilization review process. 


PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; sit; kneel, use hands to finger, handle, or feel; and talk or hear.  The employee must frequently lift and/or move up to 50 pounds.  Specific vision abilities required by this job include close vision, depth perception, and ability to adjust focus. The employee must move about the work space to access work surface and shelves, cabinets, drawers, and equipment that are at, below or above the work surface.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

An essential function of the job is to be able to comply with all applicable federal, state and local safety and health regulations that would apply to this job.

Nothing in this job description limits management’s right to assign or reassign duties and responsibilities to this job at any time as business needs dictate.  This job description reflects management’s assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned.  The information contained herein is not intended to be an all-inclusive list of the duties and responsibilities of the job, nor is it intended to be an all-inclusive list of the skills and abilities required to do the job.
 

Job Benefits

In addition to per diem nursing assignments that let you choose your location and schedule, Nursefinders offers a comprehensive benefits package that includes:

  • Excellent Pay
  • Direct Deposit
  • Comprehensive Medical Benefits (for those determined to have worked full-time after a 12 month ACA eligibility period)
  • Supplemental Benefits: Dental, Vision, Medical Indemnity, Life Insurance with optional Critical Illness and Short Term Disability.
  • 401k
  • FREE Online CEU’s to all Active Staff’
  • “Star Rewards”- performance incentives

 

About the Company

Nursefinders, an AMN healthcare company, is your trusted local and per-diem nursing staffing agency, offering thousands of top-quality nursing (RN) career opportunities in the locations and times that best suit your lifestyle. With a nationwide network of offices to serve you, Nursefinders has the most exclusive contracts with top-ranked hospitals and facilities across the nation. AMN Healthcare is an EEO/AA/Disability/Protected Veteran Employer.  We encourage minority and female applicants to apply.

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