RELOCATION ASSISTANCE AVAILABLE!!
Facility
Cape Fear Valley Medical Center
Location
Fayetteville, North Carolina
Department
Coordination of Care
Job Family
Management
Work Shift
Days (United States of America)
Summary
Participates in and oversees the operational and personnel activities as it relates to Utilization Management needs and requirements. Responsible for the coordination and management of denials and subsequent outgoing appeals between payers and Cape Fear Valley Health System. Supports a collaborative coordinated process among departments within the community, health system, physician, and support staff to promote effective management and cost containment of patient care across the healthcare continuum. Fosters teamwork and integration of services for the staff in Coordination of Care and the customers served. Adheres to patient experience initiatives and champions customer service excellence. Major Job Functions
The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:
Leads, coordinates and oversees the workload of the Utilization Management RNs
Reviews and recommends policies and procedures in relation to Utilization Management
Maintains updated knowledge of Medicare and Medicaid regulation changes and provides communication and facilitates new process changes as necessary to maintain compliance as it relates to Utilization Management activities
Audits staff’s Admission and Concurrent Reviews for accurate application of criteria
Provide education to staff as a result of comprehensive analysis of data gathered and trends identified
Responds proactively to demand letters received from all payers, ensuring that contacted timeframes for appeals are met
Serves as Medical Necessity Reviewer in conjunction with Physician Advisor for Recovery Audit Contractor Team
Educates on and facilitates compliance with Joint Commission requirements, audits, compliance, and record maintenance
Identifies and develops department and individual performance audit tools to measure compliance and quality
Identifies opportunities and solution sets and strategies to improve utilization management departmental processes to meet the evolving needs of specific patient populations, hospital, and community
Other duties as assigned
Minimum Qualifications
The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:
Education and Formal Training :
Associate’s degree in Nursing required
Bachelor's degree in Nursing preferred
Current Registered Nurse licensure in North Carolina or Compact state licensure required
Work Experience :
3 years’ experience in Utilization Management required
1 year of Case Management experience preferred
1 year prior experience with data and statistical analysis preferred
3 years in managed care claims/reimbursement or other healthcare field preferred
Must have management experience in Utilization Review, experience with insurance claims.
Must have an understanding of working with a revenue cycle.
Must understand Epic and Epic reporting.
Must be able to build reports to manage staff and improve upon an already standing UM committee.
This position requires working every 4th or 5th weekend.
Knowledge, Skills, and Abilities Required :
Proficiency in reading, writing, and speaking the English language
Knowledge of professional nursing principles, clinical processes, and clinical interventions
Working knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory services
Ability to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical records
Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
Knowledge and…