Utilization Review Coordinator / Case Management / PRN
CHRISTUS Health•Santa Fe, NM
4h•Onsite
About The Position
POSITION SUMMARY: Registered Nurse uses approved screening criteria (MCG®/CMS Inpatient List) to determine the medical necessity of a requested hospitalization and the appropriate level of care for that patient. Actively involved in the continued management of patient status/LOC. Provides consultative role as utilization management nurse to clinical and non-clinical departments. Documents objective findings against approved indicators. Assists with retrospective reviews and medical necessity denials per communication with third party payors. Follows UR policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC.
Requirements
- Graduate of an approved school of nursing, BSN preferred.
- Current licensure as an RN in New Mexico mandatory.
- Excellent reading, writing, and editing skills in English.
- Strong organizational skills.
- Knowledge of or ability to learn MCG® for determining criteria.
- Ability to effectively evaluate physician orders and medical records.
- Competent computer skills for word processing, data collection, and retrieval.
- Ability to analyze and create reports.
- Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in an acute care setting.
Nice To Haves
- Experience with utilization management
- Knowledge of MCG ®/ criteria
- Knowledge of managed care language
- Knowledge of CMS rules and regulations
Responsibilities
- Determine medical necessity of hospitalization
- Manage patient status/LOC
- Provide consultative role to clinical and non-clinical departments
- Document objective findings against approved indicators
- Assist with retrospective reviews and medical necessity denials
- Follow UR policies and procedures
- Assist with improving the quality and effectiveness of the utilization management program
