RN Utilization Review - Part Time Day Shift (thedacare)
Job posting number: #217767 (Ref:25-22518)
Job Description
Why ThedaCare?
Living A Life Inspired!
Our new vision at ThedaCare is bold, ambitious, and ignited by a shared passion to provide outstanding care. We are inspired to reinvent health care by becoming a proactive partner in health, enriching the lives of all and creating value in everything we do. Each of us are called to take action in delivering higher standards of care, lower costs and a healthier future for our patients, our families, our communities and our world.
At ThedaCare, our team members are empowered to be the catalyst of change through our values of compassion, excellence, leadership, innovation, and agility. A career means much more than excellent compensation and benefits. Our team members are supported by continued opportunities for learning and development, accessible and transparent leadership, and a commitment to work/life balance. If you’re interested in joining a health care system that is changing the face of care and well-being in our community, we encourage you to explore a future with ThedaCare.
Benefits, with a whole-person approach to wellness –
- Lifestyle Engagement
- e.g. health coaches, relaxation rooms, health focused apps (Wonder, Ripple), mental health support
- Access & Affordability
- e.g. minimal or zero copays, team member cost sharing premiums, daycare
UNIT DETAILS (Behavioral Health- Neenah Hospital):
This 19 bed unit serves a great purpose in the community treating various health needs. Our compassionate team is comprised of Psychiatric hospitalists, RN's, CNA's, Occupational Therapists, mental health therapists, utilization specialists, and administrative professionals. This environment allows for collaboration and learning on a daily basis. Our team is dedicated to the highest quality of care and fosters great learning opportunities.
SCHEDULE:
DAY shift 8-4:30p M-F
No weekends or Holidays
KEY ACCOUNTABILITIES:
Uses nationally recognized, evidence-based guidelines to complete reviews of patients for appropriateness of admission status and level of care for patient’s clinical condition.
Communicates directly with insurance companies and/or payer to obtain admission authorization and continued stay certification or recertification in a professional and timely manner. Documents utilization reviews and payer contact communication outcomes.
Evaluates and facilitates concurrent and retrospective denials, appeals, or payment issues until resolved to ensure proper reimbursement is received.
Provides status recommendations to providers and works with the healthcare team in various settings to ensure proper documentation to support medical necessity for hospital stay is included in the electronic medical record in accordance with regulatory standards.
Serves as a resource to medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities.
Communicates payer issues and medical necessity concerns with healthcare team to provide appropriate care in the appropriate setting.
Identifies and escalates trends with insurance companies, denials, documentation/order requirements, or medical necessity concerns. Identifies and escalates quality concerns related to clinical care to leadership as appropriate.
Actively contributes to and participates in utilization management committees as assigned.
QUALIFICATIONS:
Bachelor of science degree in nursing
RN license
American Heart Association Healthcare Provider Basic Life Support (BLS)
PHYSICAL DEMANDS:
Ability to move freely (standing, stooping, walking, bending, pushing, and pulling) and lift up to a maximum of twenty-five (25) pounds without assistance
Job classification is not exposed to blood borne pathogens (blood or bodily fluids) while performing job duties
WORK ENVIRONMENT:
Climate controlled office setting with daily movement throughout the facility
Interaction with department members and other healthcare providers