Number of Positions In Requisition
1
Job Details
Performs basic nursing skills, study coordination and data management, with a central focus on managing subject recruitment and enrollment, consistency of study implementation, data management and integrity, and compliance with regulatory requirements and reporting
Job Description
Summary
Performs basic nursing skills, study coordination and data management, with a central focus on managing subject recruitment and enrollment, consistency of study implementation, data management and integrity, and compliance with regulatory requirements and reporting
Job Duties Collects and documents clinical information (data) from study participants.
Provides patient education regarding research study.
Obtains informed consent and supports enrollment into clinical trials.
Interacts with consortium members, organizes meetings and communicates with participating institutions, tracks and records progress, schedules meetings, records and distributes minutes.
Minimum Qualifications Associate’s Degree Nursing Diploma or Associate’s Degree in Nursing.
Bachelor’s Degree Nursing
1 year Minimum of 1 year of RN Clinical Experience in health care setting.
3 years case management experience, discharge planning or utilization management experience required.
Knowledge of managed care, governmental and third party payors reimbursement.
Must be proficient with InterQual and mcg criteria and its application. Strong interpersonal relationships.
Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.
Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.
Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
Refers cases to the Physician Advisor per department procedures which require further review or clarification.
Applies specific relevant medical necessity criteria for all patients within 24 hours of admission to determine the appropriate patient status.
Completes retrospective clinical review for cases requiring third party payor medical necessity approval for payment.
Documents appropriate medical necessity criteria level of care guidelines subset.
Evaluates Level I medical necessity appeal results to determine appropriateness of Level II appeal. Refers case to Physician Advisor for input as needed.
Evaluates contract auditor retrospective denials for appropriateness of appeal.
Follows departmental procedures for Condition 44 downgrades, including medical record documentation, and informing patient and Case Manager.
Performs the appeal process and procedures for cases identified for IRO appeal.
Performs appeal process in coordination with specific third party payor format and protocols.
Refers cases without documentation of acute level of care to the Physician Advisor.
Researches clinical aspects of case as necessary to provide information necessary for appeal.
Tracks and maintains list of Medicare admission requiring reviews.
Documents in the patient’s medical record and work queues per department policies and procedures.
Identifies consistent issues related to denial and appeal activities and reports them to the Manager.
Adheres to organizational policies and procedures, identified third party payer contract utilization management workflows and governmental payer processes.
Case Management Safety Competencies: Identified patients using the appropriate patient identifiers. Utilizes interdisciplinary…