Rn Utilization Review/Case Management - Behavioral Health

Description

PeaceHealth is seeking a RN Utilization Review/Case Management - Behavioral Health for a Per Diem/Relief, 0.00 FTE, Day position. The general salary range for this job opening at PeaceHealth is $41.20 – $61.80. The actual hiring rate is dependent upon several factors, including but not limited to, the job/position responsibilities, location, terms of the applicable collective bargaining agreement, education, training, work experience, seniority, work performance, etc.

JOB SUMMARY

Responsible for promoting effective utilization and monitoring of healthcare resources, along with medical case management of patients with chronic unstable conditions and patients who have been recently hospitalized. This position will assume a leadership role with the interdisciplinary team to achieve optimal clinical, financial, and satisfaction outcomes.

ESSENTIAL FUNCTIONS

• Monitors all disciplines’ documentation to ensure it supports need for acute and ongoing psychiatric inpatient care in order to reduce denials. Ensures all disciplines document to Medicaid/ Medicare standards. Provides education and feedback to disciplines and/or individuals to standardize documentation.
• Attends unit leadership meetings. Collaborates regarding unit issues and quality assurance. Provides staff education as appropriate.
• Guides discussion in treatment teams to improve quality, decrease cost and improve patient satisfaction. Communicates variance days to treatment team and to manager.
• Oversees and supports Electroconvulsive Therapy (ECT) process.
• Ensures the best use of limited inpatient resources by confirming that accepted patients meet medical necessity criteria and will benefit from hospitalization.
• Maintains issue tracker related to third party denials and interfaces with management as needed to initiate investigation of denials.
• Collaborates closely with other departments such as Patient Financial Services, Health Records and Contracting to ensure efficient work process in obtaining authorizations, timely payment and proper billing in patient accounts.
• Provides professional nursing presence and oversight based on unit needs.
• Screens admission referrals in conjunction with the psychiatrist and through the filter of Behavioral Health Inpatient Unit’s admission criteria. Understands and adheres to Medicaid standards. Gathers all needed referral information to inform decision. Monitors accepted admissions from off hours and educates regarding admission criteria as needed.
• Performs medical case management, including patient education regarding chronic and complex medical conditions; monitors relevant lab values, obtains medical history, arranges medical follow-up appointment post-surgical procedures, orders medical home health, CPAP, RT etc.
• Communicates proactively and adeptly with members of the interdisciplinary team to ensure hospital and community resources are appropriately and effectively utilized on behalf of patients and their families.
• Acts as intermediary between the hospital and third party payors to ensure patients receive appropriate medically necessary inpatient psychiatric and medical services, so that the organization receives appropriate and optimal reimbursement.
• Maintains issue tracker related to CDMP issues and communicates medical co-morbidities to treatment team. Identifies and evaluates medical co-morbidities for billing purposes.
• Works closely with Patient Financial Services to assist in decreasing denials.
• Oversees and supports staff with wound care and patient education.
• Communicates adeptly and within designated time frames with third party payors in order to obtain authorizations and resolve payment issues on behalf of patients and families and the organization.

QUALIFICATIONS

EDUCATION:

• Bachelor’s degree required or completed within one year of hire.
• Graduate of an accredited State Board of Nursing approved nursing program required

EXPERIENCE/TRAINING:

• Working knowledge of psychiatric diagnostics required
• Third party reimbursement knowledge desirable
• Minimum of 3-5 years psychiatric clinical work required

LICENSE/CERTIFICATION:

• Willingness to work toward CPUR certification preferred
• Current RN licensure in state of practice required

OTHER SKILLS:

• Strong medical background and knowledge of critical care
• Excellent problem solving and critical thinking skills
• Strong communication skills, both verbal and written
• Ability to maintain documentation systems of care and tracking of patients
• Ability to develop and maintain patient resources for education and referral
• Understanding of Medicaid/Medicare standards and requirements
• Proficient use of computers including MS Office applications and other applicable software applications.
• Must be able to work both independently and interdependently with staff and team members with limited supervision.
• Ability to develop strategies for staff and patient education
• Strong organizational and critical thinking skills

RIVERBEND- PHYSICAL/COGNITIVE REQUIREMENTS:

• Job duties frequently require intense concentration and attention to detail (34-65% of work time).
• Work may require frequent exposure to conditions involving minor cold, heat, poor ventilation or sharp instruments such as syringes or lancets. Reasonably anticipated exposure to blood and body fluids once per month or more.
• Work requires normal amounts of physical effort at least 66% of the time.
• Ability to lift objects weighing 25 lbs. or less.

PeaceHealth is committed to the overall wellbeing of our caregivers. The benefits included in positions less than 0.5 FTE are 403b retirement plan for caregiver contributions; wellness benefits, discount program, and expanded EAP and mental health program.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.

Must be fully vaccinated or exempted for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date. PeaceHealth has a medical and religious exemption request process for those that are unable to receive the COVID-19 primary vaccine series due to medical/religious reasons.