Registered Nurse - Utilization Management - Full Time (varied hours) - Jefferson

Jefferson Health Plans • Philadelphia, PA

27d

About The Position

Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care. Job Description interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Case Management Condition 44 process. Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Performs appeal process in coordination with specific third party payor format, protocols, and timelines.

Responsibilities

• Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status.
• Performs denial and appeal activities for inpatient hospital care.
• Refers cases to the Physician Advisor per departmental procedures.
• Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.
• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Case Management Condition 44 process.
• Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.
• Performs appeal process in coordination with specific third party payor format, protocols, and timelines.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed