RN Utilization Review Outpatient Full-time
North Mississippi Health Services

Coordinator-RN Utilization-3p-11p

North Mississippi Health Services Tupelo, MS, US
Posting Description

We believe a career is more than just a career — it's a calling. Our teammates' "True North" is what calls them to health care; it’s their passion. At North Mississippi Health Services, we believe in helping you leverage and connect that passion with a much greater purpose that impacts people you know and love.

Essential FunctionsList major areas of responsibility and briefly what the person does in each area. Coordinates:

  • Consults with physician services
  • Utilizes clinical diagnostics, physician documentation and non-physician clinical guidelines to facilitate status determination of inpatient, outpatient or outpatient observation.
  • Coordinates final status with admitting and attending physicians
  • Performs initial and concurrent clinical reviews as indicated by payer and patient clinical needs
  • Inpatient and/or outpatient notification and precertification of services to payers
  • Facilitates peer to peer, written reconsiderations or appeals throughout all denial cycle as appropriate
  • Facilitates appropriate observation utilization
  • Consults with patient financial services

Educations:

  • Provides education and literature to physician services regarding IPPS and OPPS
  • Educates physicians and other care team member on level of care criteria and other third party payer requirements

Reporting/Recordkeeping:

  • Updates patient’s medical records as required
  • Shares medical necessity documentation with payers to facilitate reimbursement

Regulation:

  • Adheres to NMHS/NMMC Policies/Procedures/Guidelines
  • Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues

Know How

Job Knowledge

Specify required education, licensure/certification, prior experience, skill behavior, equipment operation, type and duration of on-the-job training, patient population to be served, etc.

  • Associates Degree in Nursing, required; Bachelor’s Degree preferred
  • Licensed as a Registered Nurse by the Mississippi Board of Nursing; required
  • Minimum of 5 years clinical and/or healthcare experience; required
  • Excellent organizational and communication (written and verbal) skills; required
  • Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required
  • Certified as an Accredited Case Manager (ACM); desirable
  • Excellent interpersonal skills; required
  • Demonstrates ability to care for a patient population from pediatric to geriatric; required

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