Job Description

*****On-Site Not Remote: Full Time and Per Diem Open Positions

Perform focused Utilization Review applying criteria such as MCG, InterQual’s ISD-A, or payer- specific criteria. Determine level of care and fiscal impact. Provide information to payers to achieve maximum reimbursement. Address over and underutilization of hospital resources concurrently, including issuance of appropriate notices.

*Conducts intermittent chart reviews for all patients admitted to ensure that patients meet level of care for admission and continuing care.

• Demonstrates the application of MCG criteria, as an integrated monitor to ensure adequate clinical documentation for appropriate Length of Stay.

*Provides clinical data as part of the telephonic or electronic review process to external parties (as required) to ensure continued stay authorizations.

*Coordinates Physician Advisor referrals when there are concerns regarding meeting level of care criteria (utilizing MCG). Reviews PA referrals with department manager.

*Demonstrates the application of MIDAS utilization for admission reviews and continued stay documentation.

*Demonstrates knowledge of managed care and third party payor regulations including Medicare and Medicaid level of care standards and requirements.

*Participates in hospital and/or department committees or teams as requested or appointed by the department manager

Qualifications

Job Requirements :

Education:

• Graduate of an accredited School of nursing is required. BSN and CCM preferred.

Experience & Skills:

• Minimum of two (2) years acute hospital clinical experience is required.
• Recent experience in case management, utilization review, discharge planning, ongoing monitoring and evaluation of patient care delivery process is necessary.
• Must be self-directed, assertive and creative in problem solving, systems planning and patient care management in high volume work environment.
• Ability to work effectively, collaboratively with multi-disciplinary teams in multiple environment is necessary.

Licensure/Certification:

• Florida RN license required

Additional Information

All your information will be kept confidential according to EEO guidelines.