RN Coordinator-Utilization

North Mississippi Medical Center, Inc

United States

On-site

USD 65,000 - 81,000

Full time

3 days ago

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Job summary

North Mississippi Health Services seeks an RN Utilization Coordinator to coordinate utilization management activities, perform clinical reviews, educate care teams, and ensure regulatory compliance. You will collaborate with physician services and payers to determine appropriate care levels and ensure timely approvals.

The role requires strong nursing credentials and experience in a multidisciplinary setting with a variable schedule, primarily Monday–Friday with some weekend work.

Qualifications

Minimum RN licensure with active state license.
Strong organizational and written/verbal communication skills.
Knowledge of payer sources, regulations, and cost containment.
Ability to work independently and in a team.
Experience coordinating utilization or case management is a plus.

Responsibilities

Consults with physician services.
Utilizes clinical diagnostics to facilitate status determination of inpatient, outpatient or observation.
Coordinates final status with admitting and attending physicians.
Performs initial and concurrent clinical reviews as indicated by payer and patient needs.
Notifies and precertifies inpatient/outpatient services to payers.
Facilitates peer to peer, written reconsiderations or appeals.
Consults with patient financial services.

Skills

Nursing

Regulatory knowledge

Communication skills

Payer knowledge

Team collaboration

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job 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.

Department: 10007915 Utilization Management

Work Shift: Variable shift, Monday thru Friday primarily with some weekend work

Job Description:

The RN Utilization Coordinator at North Mississippi Health Services is responsible for coordinating and performing various tasks related to utilization management and case management services. They work with physician services, perform clinical reviews, educate care team members, and ensure compliance with regulatory guidelines.

JOB FUNCTIONS

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.

Knowledge Skills and Abilities

Excellent organizational and communication (written and verbal) skills; required
Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required
Excellent interpersonal skills; required
Demonstrates ability to care for a patient population from pediatric to geriatric; required
Works independently as well as in a team setting
Resolves problems/issues related to patient outcomes
Assists with departmental Performance Improvement (PI)
Assures compliance with regulatory guidelines and applicable laws/statues
Must have excellent written and verbal communication skills
Must reflect a positive, caring attitude toward clients, patients, staff and the public we serve

Physical Demands

A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.