Utilization Review Registered Nurse-Care Management-Rapid City

Regional Health Rapid City , SD 57702

Posted 2 months ago

Department

RCH Care Management

Scheduled Weekly Hours
20

Shift

Day (United States of America)

Job Summary

Responsible for review and completion of denial/appeal requests. Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations. Will collaborate with Case Managers, Utilization Review Medical Directors, Corporate Compliance, Admissions and Patient Financial Services on patient status for accuracy of billing. Responsible for utilization review duties in collaboration with Case Managers. Completes audits for appropriate utilization of resources, develops/implements action plans when appropriate. Establishes goals and priorities consistent with mission and goals of Rapid City Regional System of Care, as well as meets requirements of Joint Commission and other applicable federal, state and local regulatory and/or accrediting bodies.

Job Description

Essential Functions

  • Advocates for payment of services, collaborates with physicians and the UR Committee.

  • Completes requested audit for medical necessity, develop/implements action plans appropriately. Reports delays to Department Leadership.

  • Facilitates the completion of Case Management services and discharged medical record review as needed for medical necessity and appropriate patient status / service and plan of care. Assists in timely completion of denial reviews and assists to identify any trends.

  • Promotes the optimal allocation of health dollars through accurate, effective and timely appeals.

  • Stays current with the provider aspect of federal/state organization regulations related to inpatient and observation hospital level of care.

  • Supports compliance with Utilization Review and regulatory guidelines. Identify trends related to compliance of regulations and collaborates with appropriate hospital personnel and external agencies to ensure appropriate process changes are implemented.

  • Applies up-to-date information related to reimbursement procedures, managed care contracts.

  • Fosters and role models an atmosphere of interdisciplinary collaboration and communication across the system and with both internal and external entities and disciplines.

  • Any other duties as assigned.

Additional Requirements

Required:

Education

  • Associates in Nursing

Certification

  • Registered Nurse (RN) - South Dakota Board of Nursing

Preferred:

Education

  • Bachelors in Nursing

Work Experience

  • 5+ years Acute Experience; 5+ years Healthcare Financial Management Experience; 3+ years Microsoft Office Word Excel and PowerPoint

Sedentary work

  • Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

Come join us in our pursuit to become the best healthcare system in America!

Regional Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.


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Utilization Review Registered Nurse-Care Management-Rapid City

Regional Health