利用管理专员（居家办公）- 预授权
Utilization Management Specialist (Home-Based) - Prior Authorization
Sanford Health 是美国最大的农村医疗体系，致力于改善医疗体验，并为美国中部地区提供世界级的医疗服务
工作班次：
日班（美国）
每周计划工时：
40 小时
薪资范围：
27.50 美元 - 38.50 美元
是否工会职位：
否
部门详情
提供远程工作的机会
简介
在患者的病历中进行护理级别医疗必要性审查。根据使用管理（UM）计划执行使用管理活动，确保符合认证/监管要求。完成与 UM 和/或事先授权流程的实施、持续评估和改进相关的活动。完成与医疗必要性判定、授权、继续住院审查相关的活动，包括诊断和操作编码，以确定工作诊断相关组（DRG）分配
职位描述
工作流程可能包括病历审查，协助并管理保险覆盖和拒付，事先授权，计划手术，同日再入院审查，以及住院时长。确保在入院前对术前手术审查中的适当护理级别进行验证。审查包括 InterQual 临床决策支持标准，以确保医疗服务的适当性和有效的成本控制。能够判断不符合部门标准的转介案件的适当处理方式，并在需要时进行二次审查和/或升级。也可能积极参与与医疗团队成员合作，促进医疗必要的资源利用，并在适当的时候实现财务目标。根据需要与医生和其他临床专业人员合作，协助改进文档实践，以提供有效和适当的医疗服务。具备与医生和其他医疗专业人员有效沟通的动态和灵活的人际交往技能。向医疗团队成员教育有关趋势、外部法规和内部政策，这些政策影响资源利用和可能的事先授权。协助部门按照指南和标准监控资源利用、风险管理和患者护理质量。协助准备报告、通信和维护适当的记录。确保
查看英文原文
Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.
Work Shift:
Day (United States of America)Scheduled Weekly Hours:
20Compensation:
Salary Range: $27.50 - $38.50Union Position:
NoDepartment Details
Knowledge of oncology is preferredSummary
Conduct level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.Job Description
Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay. Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed. May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization. Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements.May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.Qualifications
Bachelor's degree in nursing preferred. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.Sanford is an EEO/AA Employer M/F/Disability/Vet.
If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-949-5678 or send an email to .
Originally posted on Himalayas