Catholic Health Initiatives Louisville , KY 40202
1st Shift, Full Time
Works collaboratively with physicians, staff and other health care professionals within his/herDivision to review andmonitor members' utilization of health care serviceswith the goal of maintaining high quality costeffective care. The role includes providing the clinical and utilizationexpertise necessary to evaluate the appropriateness and efficiency of medical servicesand procedures.
This includes providing referral authorization, concurrentreview, appropriate referral to casemanagement, and high dollar claims review.The Utilization Management RN is an integral memberof the health care teamas well as the DivisionalCare Management team. Collaborates with the Divisional Care Managementteam on system-wide quality improvement/performance improvementinitiatives.
ESSENTIALFUNCTIONS:Performsinitial, concurrent and retrospectivereviews on all inpatient,facility and appropriate home health services.Ensuresappropriate placement and monitors level and quality of care.In conjunctionwith, and under the supervision of physicians, evaluatesand provides feed-Addressescare issues with Manager of Care Management Physician Advisor and Chief Medical Officer/Medical Director asappropriate.Coordinatesidentification and reporting of potential high dollar/utilization cases to reinsurerand finance department forappropriate reserve allocation.Consults with physicians,health care providers and outside agenciesregarding continued care/treatment or hospitalization.Identifiesand recommends opportunities for costsavings and improving the qualityof care across the continuum.Clarifieshealth plan medical benefits, policies and proceduresfor members, physicians, medicaloffice staff, contract providers, and outside agencies.Review perdiem patients daily for medicalnecessity to ensure reimbursement. Responsiblefor the early identification and assessment of membersfor potential inclusion in a comprehensivecase management program. Refers members for case Management accordingly.Actively participatesin the discussion and notification processes that resultfrom the clinical utilizationreviews with the facilities.Reviews any servicedenials and gathers necessary supporting documentation from chart audits and followsup according toprocedures.Assists in theidentification and reporting of Potential Quality of Careconcerns.Responsiblefor assuring these issues are reported to the Care Management Manager.Providesbackup for Case Manager.Work asan interdisciplinary teammember within Divisional Care Management departments.
Current unrestrictedlicense, as a registered nurse, in state(s) of practice is required.
BLS Certification preferred.
Bachelor of Sciencein Nursing required;Masters of Sciencein Nursing preferred. Will accept equivalentexperience in lieu of degreeif the candidate obtains his/her BSN within3 years post hire.
Minimum 3 yearsclinical experience as Registered Nurse (RN) required.
Minimum 5 yearsutilization management experience preferred.