Overview:
USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provides the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall well-being of our community.
Responsibilities:
Responsibilities Performs functions independently, according to policy and third party payor requirements, to include: quality reviews, prior authorizations, initial/admission reviews, continued stay reviews, discharge reviews, retrospective reviews, appeals as appropriate for denials, and case management reviews for DRG payors
Analyzes medical record data to complete functions
Collaborates with members of the healthcare team, patients, families, and managed care workers to formulate appropriate discharge plans and promote a safe and timely flow through inpatient setting
Ensures optimal reimbursement from third party payors through appropriate implementation of Utilization Review functions
Communicates with healthcare providers via telephone, in person, and email (i.e., discussion with physicians regarding plan of care, length of stay, and stay type)
Establishes and maintains a professional relationship with third party payor representatives
Participates in interdisciplinary patient care meetings as assigned
Utilizes a PC to access the Hospital Information System
Enhances professional growth and development through participation in educational programs
Completes annual education on nationally recognized level of care criteria
Participates in all Utilization Review audit activities as assigned
Orients new staff to the Utilization Review process as assigned
Reports quality of care concerns discovered during Utilization Review functions to the Director
Evaluates chart documentation for completeness relative to current ICD requirements and communicates deficiencies
Demonstrates proficiency in Early Periodic Screening Diagnosis and Treatment (EPSDT) by performing independently, according to regulatory requirements, the following functions as assigned
Identification of patient eligibility, collection of data required to perform screening, performance of Inter-periodic Screening Components, and communication of screening findings to all related parties
Maintains accurate and complete records both written and via personal computer
Documents reviews according to hospital policy
Completes/documents forms/requests from third party payors and regulatory parties
Documents variances, discharge plans and EPSDT functions
Utilizes proper body mechanics when moving equipment that is necessary to perform essential functions
Communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone
Responds to overhead pages
Accesses and accurately maintains electronic and paper medical records
Participates on committees as assigned
Participates in Performance Improvement activities as assigned
Completes all mandatory department, educational and hospital requirements
Adheres to current Infection Control and Safety Standards
Regular and prompt attendance
Ability to work schedule as defined and overtime as required
Related duties as assigned
Additional Information:
Employees must be in a regular position, working 20 hours or more per week (.50 FTE or greater) to qualify for benefits.
Qualifications:
Graduation from an accredited school of nursing meeting the minimum standards set by the State of Alabama and 2 years or professional nursing experience Required
Bachelor's Degree or Master's Degree in nursing Preferred
Utilization Review experience Preferred
RN - Registered Nurse - State Licensure and/or Compact State Licensure Required
Comparable combination of education and experience may substitute for the above requirements.
Equal Employment Opportunity Employer:
The University of South Alabama is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status or any other applicable legally protected basis. EO Employer – minorities/females/veterans/disabilities/sexual orientation/gender identity.
Numbers & Facts
Location
Mobile, Alabama
Job Type
Full-time
Skills
Alliance/Partner Marketingunmatched
Case Managementunmatched
Customer Relationsunmatched
Data Analysisunmatched
Data Collectionunmatched
Diagnosis-Related Group (DRG)unmatched
Discharge Plansunmatched
Documentationunmatched
Electronic Medical Recordsunmatched
Employee Orientationunmatched
Healthcareunmatched
Healthcare Providersunmatched
Healthcare Reimbursementunmatched
Hospital Systemsunmatched
Infection Controlunmatched
Information Technology & Information Systemsunmatched
International Classification of Diseases (ICD)unmatched
Managed Careunmatched
Medical Recordsunmatched
Medicineunmatched
Nursingunmatched
Nursing Credentialsunmatched
PC (Personal Computer) Systemsunmatched
Patient Careunmatched
People Managementunmatched
Performance Managementunmatched
Quality of Careunmatched
Registered Nurse (RN)unmatched
Regulatory Requirementsunmatched
Safety Standardsunmatched
Schedule Developmentunmatched
Single Sign-On (SSO)unmatched
Time Managementunmatched
Treatment Planunmatched
Utilization Managementunmatched
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