UR QUALITY ASSURANCE NURS - CASE MANAGEMENT
Status: Full Time
Shift: M-F 8a-4:30p
Exempt: No
Summary:
The Case Management Quality Assurance UR Nurse is a Registered Nurse who is a member of the case management team and will be responsible for ensuring quality decision making and compliance with all regulatory requirements of the Case Management staff working with those that do not meet the standards. Additionally, the case management QA/UR nurse will assist in retro reviews, appeals, and short-stay IP reviews.
Other information:
1.Previous Experience Required: Minimum 3 years of nursing experience of which at least 2 are clinical nursing.2 years Case Management/Utilization Review preferred
2.Specialized or Technical Education Required: Registered Nurse with an unrestricted License in the State of Louisiana; BSN preferred. Membership in a professional organization is encouraged.
3.Manual or Physical Skill Required: See below
4.Physical Effort Required/Physical Demands:
Strength: Medium
Push: Frequently
Pull: Frequently
Carry: Occasionally
Lift: Occasionally
Sit: Occasionally
Stand: Frequently
Walk: Frequently
Responsibilities:
1.Completes QA monitors and trending for all metrics associated with the department as assigned.
2.Reviews and manages assigned workques.
3.Assists with daily utilization review functions as needed or assigned, including payer interactions, reviews for status changes, and peer-to-peer management.
4.Reviews all Medicare short-stay inpatient accounts, working in conjunction with members of the Utilization Review committee to determine accurate billing status.
5.Reviews Medicaid denials and determines appropriateness for 3rdparty appeal.
6.Assists with retro authorizations as needed
7.Temporarily accepts and functions in a primary care assignment as an RN Care Manager at NOMC, performing all duties listed in the RN Care Manager job description addendum specific to each department as departmental priorities and activities dictate.
8.Acts as a credentialed trainer and resource for EPIC electronic medical record and MCG/Interqual status tools.
9.Assists with departmental audits as assigned to include level of care reviews, documentation, and compliance audits.
10.Utilizes effective and professional communication with all personnel, physicians, patients, families and visitors.
a.Promotes satisfactory relationships
b.Shares knowledge/acts as a resource
11.Adheres to all policies, procedures and protocols established by North Oaks Medical Center.
12.Participates in professional development activities.
a.Attends department meetings
b.Completes CBL assignments by deadlines
c.Attend mandatory and prn educational offerings
13.Assists in operational functions
a.Supports strategic initiatives
b.Participates in QI projects as assigned
c.Accepts other projects as requested
14.Follows North Oaks Health System compliance program and Federal and State Regulatory guidelines.