Weekend Only RN Clinical Review Management
US-ID-Boise
careers
Req #: 100293
Type: Full-Time
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Overview: At St. Luke's, our dedicated team of Clinical Review Nurses strive to build a positive, supportive, and inclusive culture that delivers exceptional patient experiences. SIGN ON BONUS ELIGIBLE What You Can Expect: * On site, 10 hour shifts * Friday, Saturday, Sunday, Monday * Weekend premium eligible * 6 weeks intensive paid training * Responsible for evaluating medical necessity for patient hospitalization and acting as an internal resource for patient care * Fully Benefitted Qualifications: * Education: Bachelor of Nursing or Associates of Nursing Degree * Experience: 3 years of RN or utilization management experience (BSN) or 5 years of RN or utilization management experience (ASN) * Licenses/Certifications: Current RN license in Idaho Responsibilities: The RN Clinical Review Management is responsible for evaluating medical necessity for patient hospitalization and acting as an internal resource for patient care. Ensures that utilization functions are complying with hospital procedures and federal regulations. * Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term services and Supports, and Home Health. * Reviews the medical necessity of admission, continued hospitalization, length of stay, and any potential denial of payment issues. Applies established criteria and employs clinical expertise to interpret clinical criteria to determine medical necessity of services. Performs Medicaid and Medicare review. * Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Communicates results of reviews to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements. * Partners with physician's and other clinical departments to ensure appropriate cost-effective care. Facilitates escalated reviews in accordance with Standard Operating Procedures and in collaboration with clinical, medical staff and peer review teams. Handles complex utilization management related issues, seeks consultation when appropriate. * Provides decision-making guidance to clinical teams on service planning. Ensures compliance with hospital, state, and federal regulations and requirements. * Documents clinical decisions accurately and timely, working with utilization management leadership to ensure consistency in applying policy, as needed. Works with utilization management and clinical leadership teams to ensure policies, procedures, and regulatory and contractual requirements are met. * Provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates with physician's related to appropriateness of admission and the prevention of denials. Intervenes when potential denials are determined and facilitates appeals when concurrent denials are received. Creates and maintains database of denied service requests. * Maintains a broad knowledge of health care delivery that includes but is not limited to managed care regulations, contract terms/stipulations, utilization review and governmental agency regulations. * Perform other duties and responsibilities as assigned. Qualifications: * Education: Bachelor of Nursing or Associates of Nursing Degree * Experience: 3 years of RN or utilization management experience (BSN) or 5 years of RN or utilization management experience (ASN) * Licenses/Certifications: Current RN license in State of Practice
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