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Wexford Health’s Quality Management and Corporate Compliance department is made up of certified clinical auditors, licensed nurses and other industry experts who focus on quality improvement/assurance, accreditation and clinical training.

Registered Nurse - Utilization Management Job



Job Number: 73986681051

Location: Pittsburgh, PA

Date Posted: 11-11-2016

 

Wexford Health Sources, one of the nation's leading innovative correctional health care company, provides clients with experienced management and technologically advanced services, combined with programs that control costs while ensuring quality.  For nearly two decades, Wexford Health has consistently delivered proven staffing expertise and a full range of medical, behavioral health, pharmacy, utilization management, provider contracting, claims processing, and quality management services.

At Wexford Health our philosophy is that health care should not be considered a luxury for anyone.  We simply care for those in need and the corrections environment is our venue.

Wexford Health has an exceptional opportunity for a Utilization Management Nurse (RN) to join our team of healthcare professionals at our Corporate Office in Green Tree, PA.

We’re proud to offer a competitive benefits package including:

  • Annual review with performance increase
  • Generous paid-time off program that combines vacation and sick leave
  • Paid holidays
  • Comprehensive health insurance through Blue Cross Blue Shield
  • Dental and Vision insurance
  • 401(k) retirement saving plans
  • Company-paid short-term disability
  • Healthcare and dependent care spending account

POSITION SUMMARY

The Utilization Management Nurse (RN) ensures cost effective outcomes while maintaining a focus on quality care for inpatient and/or outpatient services. He/she monitors on-going medical needs and services by engaging in the following: evaluating medical necessity, appropriateness and efficient use of Health Care Services for inpatient hospitalizations and/or outpatient procedures, working closely with physicians, hospital utilization management and correctional facilities to provide quality, cost-effective care at the level most appropriate to the inmate-patient; and providing reports and recommendations to medical and facility staff for improved utilization of resources.

DUTIES/RESPONSIBILITIES

INPATIENT SERVICES:

  1. Work with patients and providers for the patients' best interests by helping to ensure appropriate care and maximizing clients' medical benefits;
  2. Review clinical information provided by the Hospital Utilization Management Departments for appropriateness of care, medical necessity and appropriate level of care; ?
  3. Utilize InterQual Criteria and/or Milliman Admission Criteria to guide admission necessity and continued stay review.
  4. Maintain a paper case of clinical information; and access computer system to obtain reference numbers for hospital billing and claims payments.
  5. Review clinical information with appropriate Medical Director and Director of Nursing to facilitate discharges back to the infirmary.
  6. Work with Operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
  7. Issue notices of non-coverage in conjunction with Statewide UM Medical Director.
  8. Prepare appeals of non-covered services for medical director review and update computer system as appropriate.
  9. Maintain monthly tracking statistics for communication log compliance and for repeat admits.
  10. Prepare daily summary report and distributes to appropriate personnel.

OUTPATIENT SERVICES:

  1. Review each region’s collegial log for completeness, in preparation for collegial discussion and ensures that consult requests are documented in each patient’s medical record
  2. Review all requests for outpatient/onsite services and obtains history and clinical rationale. Reviews and maintains all contractual turnaround times.
  3. Obtain all necessary clinical information, history, criteria, and present findings to UM Medical Director for inpatient and/or outpatient review.
  4. Participates in collegial discussions; enter all information, from the collegial discussion in accordance with contractual turnaround times, into Wexcare.
  5. Review launch reports to monitor appropriateness and accuracy of the entry process.
  6. Verify response back to schedulers with results of Collegial within contractual timeframe
  7. Work with schedulers to ensure that appointments are obtained and that patients are seen within 60 days of approval
  8. Provide site and providers with authorization number/letter according to policy.
  9. Pre-certify specific surgical cases as outlined in the policy and procedures.
  10. Review history of all consults and raise question of a possible quality of care issue or risk management issue to UM Medical Director or Director of UM.
  11. Work with Operations personnel to resolve vendor claims issues such as inappropriate coding, over or duplicate billing for services, and reimbursement issues.
  12. Assist Team with contractual issues and updates.

ADDITIONAL DUTIES AND RESPONSIBILITIES:

  1. Assist callers with questions, refer when appropriate.
  2. Prepare statistical reports for UR and Operations personnel.
  3. Provide overview of Utilization Management purpose and function to new Health Care Unit Administrators and other site personnel as requested by the Director, Utilization Management.
  4. Assist with orientation of new UM staff and site staff as indicated.
  5. Work with Medical Directors to identify areas of concern and quality improvement
  6. Work with Director of Utilization Management and other UM staff on special projects.
  7. Research inappropriate/administrative transfers of medically unstable inmates
  8. Actively participate in Utilization Management staff meetings.
  9. Collect data to monitor facility compliance to Company standards and policies
  10. Be knowledgeable of Department of Correction Policy/Procedures and Contractual Agreements with providers

The duties and responsibilities outlined herein are for payroll purposes only; employees may be assigned other duties as required.

ENVIRONMENTAL CONDITIONS

Standard office environment in a Corporate office setting which includes daily interfacing with Administration, Finance and health care personnel.


 

LICENSING: Current Registered Nursing license within the state.

CERTIFICATION: Current CPR certification.

EDUCATION: Graduate from an accredited School of Nursing

PREFERRED EXPERIENCE:

  • Prefer a minimum of two (2) years of clinical experience
  • Correctional experience, a plus

OTHER PREFERRED KNOWLEDGE, SKILLS AND ABILITIES:

  • Self-directed
  • Strong interpersonal, and verbal and written communication skills
  • Demonstrated experience meeting multiple deadlines.
  • Ability to competently manage multiple priorities simultaneously
  • Ability to work in a stressful environment
  • Must be a "team-player" as this position requires daily coordination with other coworkers.

EOE/M/F/D/V


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