This is a Full Time Work-From-Home position.
Nurse Utilization Review FT Work from Home
HCA MidAmerica division consists of 13 hospitals in Missouri, Kansas, Mississippi, and Louisiana.
HCA MidAmerica is part of HCA, one of the nation's leading providers of healthcare services.
Though HCA is made up of locally managed facilities that include 177 hospitals and 119 free-standing surgery centers located in 21 states and in the United Kingdom, we are all part of one incredible story about 270,000 talented and diverse colleagues, united in a mission to care for and improve human life. We are grounded in a culture that is patient-focused and compassionate, and we are supported by an organization whose unique scale unlocks possibilities.
HCA is dedicated to the growth and development of our colleagues. We will provide you the tools and resources you need to succeed in our organization. We are currently looking for an ambitious Full Time WFH Utilization Review Nurse to help us reach our goals. Unlock your potential here!
OPERATIONAL DUTIES INCLUDE BUT ARE NOT LIMITED TO:
This position will focus on initial and continued stay utilization review and denials to include assessment of medical records for appropriateness, level of care provided, including assessment of treatment, modalities, medications, services and application of treatment protocols. A team approach with the facility Case Management team is critical.
Perform admission InterQual as per Plan contract or within 24 hours on all Non-Medicare, non-Observation and non-Mother/Baby inpatients.
Document note to support Inpatient admission.
Review for MD inpatient order.
Ensure the patient's status is correct.
Perform continued stay InterQual as per Plan contract, a minimum of every 3 days and submit to the Plan.
Review concurrent denials and work with facility, physician and Plan to overturn the denial.
Communicate denial status to the facility and physician.
Follow all HCA standards regarding documentation and education.
Communicate with physicians regarding patient status.
Communicate medical necessity and responder criteria to the facility Case Manager.
Review the Certification / Authorization report daily to determine deficiencies.
Documentation to take place in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module.
We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO, medical, dental, flex spending, life, disability, tuition reimbursement, employee discount program, employee stock purchases, program and student loan repayment. We would love to talk to you about this fantastic opportunity.
We are an equal opportunity employer and we value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status."
At least one year InterQual experience required
Acute Care hospital experience
Third Party Payer experience helpful
Denial Management helpful
You must reside within 100 miles of the nearest HCA facility