案例经理，注册护士 - 利用审查 - 非全日制
Case Manager, RN - Utilization Review - PRN
职位名称：
病例管理员，注册护士 - 利用审查 - 临时工
部门：
OUMC 利用审查
职位描述：
请向您的招聘人员咨询我们新的市场领先薪资！
远程资格：候选人必须在入职第一天前居住并全职工作于阿肯色州、堪萨斯州、密苏里州、俄克拉荷马州或德克萨斯州。如果您不在这五个州居住且不会搬到上述批准的州之一，请不要申请。
班次：临时工
**临时工职位要求每月至少工作2个班次**
利用审查注册护士病例管理员是一位能够出色评估医疗服务和治疗的医疗必要性和适当性的专业人员。他们确保患者获得适当的护理，与保险公司、患者和跨学科提供者密切合作，以获得住院或治疗的授权。利用临床知识和基于证据的工具，注册护士病例管理员准确地审查和解读医疗记录，管理付款方拒绝的情况，同时保持患者满意度。凭借出色的沟通能力和高级问题解决能力，使用技术来保护HIPAA受保护的健康信息。
核心职责
本部分列出的职责是该职位的核心。无法在不进行合理调整的情况下履行这些职责可能导致被取消该职位的资格。
- 使用基于证据的标准工具，对患者的健康状况、病史和持续护理需求进行全面评估。
- 与跨学科医疗团队、付款方、患者及家庭协调，确保适当的状况和财务报销。
- 向患者及其家庭提供有关其医疗住院情况和符合规定监管和财务期望的适当状况的教育。
- 协调并促进患者、家庭、医疗提供者和付款方之间的沟通，以优化适当的患者和医疗系统财务报销结果。
- 评估基于证据的标准工具和付款方平台的有效性，识别问题并上报领导以推动必要的调整。
- 评估医疗资源使用模式，根据付款方合同和医疗强制性监管指南，识别提高效率和成本效益的机会。
- 为满足患者和系统需求而倡导并展示适当标准状态的使用，同时遵守相关规范。
查看英文原文
Position Title:
Case Manager, RN - Utilization Review - PRNDepartment:
OUMC Utilization ReviewJob Description:
Ask your recruiter about our new market-leading rates!
Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment. Please do not apply if you reside outside these 5 states and will not relocate to one of the approved states listed.
SHIFT: PRN
**PRN POSITIONS REQUIRE A MINIMUM OF 2 SHIFTS/MONTH**
The Utilization Review RN CM is a competent professional who excels in evaluating the medical necessity and appropriateness of healthcare services and treatments. They ensure patients receive appropriate care, working closely with insurance companies, patients, and interdisciplinary providers to secure authorizations for hospital stays or treatments. Utilizing clinical knowledge and evidence-based tools, the RN CM reviews and interprets medical records accurately, managing payor denials while maintaining patient satisfaction. With strong communication skills and advanced problem-solving abilities, using technology to safeguard HIPAA Protected Health Information.
Essential Responsibilities
Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.
- Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing Evidence based criteria tool.
- Coordinates with the Interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and Financial reimbursement.
- Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
- Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
- Evaluates effectiveness of Evidence based criteria tool and Payor platforms identifying issues and escalates to Leadership to facilitate adjustments needed.
- Evaluate healthcare utilization patterns and identify opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
- Advocates for and Demonstrates use of appropriate criteria status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria.
- Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
- Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement and escalates issues to Leadership.
- Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction.
- Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.
- Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
- Precepts newly hired Nursing Utilization Review care managers.
- Participates in departmental activities such as secondary case review, policy maintenance, quality and/or performance improvement, and assigned workgroups.
- Maintains continuing Education with approved evidence-based criteria tool and Departments process competencies and participates in quality audit review findings.
- Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
- Performs other duties as needed.
- Lead Care Management team meetings and interdisciplinary rounds.
- Complete Leadership academy leadership classes as assigned.
General Responsibilities
· Performs other duties as assigned.
Minimum Qualifications
Education Requirements
· Bachelor's Degree in Nursing required.
Experience Requirements
· At least 3 years of Nursing experience required, with Care Management experience preferred.
License/Certification/Registration Requirements
· Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).
Knowledge/Skills/AbilitiesRequired
- Demonstrates expertise in regulatory requirements regarding the Utilization Review care management discipline.
- Strong communication, interpersonal, and leadership skills.
- Detailed- oriented with excellent organizational skills.
- Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
- Strong assessment, critical thinking, and problem-solving skills
- Strong knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements.
- Show clear understanding of utilization management principles and integrate these with Nursing care management responsibilities.
- Serve as liaison between patients, families, Payors and healthcare providers.
- Demonstrates HIPPA compliance in a Work from home environment to safeguard PHI.
- Proficiency in utilizing electronic health records (EHR) and care management software
- Strong assessment, critical thinking, and problem-solving skills.
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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.
Originally posted on Himalayas