Health Services RN

PRIMARY FUNCTION:  Responsible for supporting all Health Service departments, i.e. referrals, inpatient, SNF & appeals.  Responsible for special projects as assigned.



 

Responsibilities:

 

Performs all UR activities according to Health Services policies and procedures.

Evaluates & authorizes medical necessity of inpatient & outpatient services as assigned by application of approved criteria.

Learns all areas of the department in order to provide support & coverage as needed .

Refers cases to Medical Director as appropriate.

Works with appeals department to ensure timely effectuation of appeals.

Maintains confidentially in all aspects of operations.

Maintains strong working relations with internal and external customers.  Presents communication in a positive and professional approach.

 

Assist the Health Services Director & Medical Director in tasks as assigned.

 

Evaluates & manages SNF cases, including initial approval & continued stay review.

 

 

 

Experience:

· Current Licensure as a practical or registered nurse in the state of Illinois.

· 2-3 years clinical experience with at least 1-2 years in utilization review. Managed care experience preferred.

· SNF experience preferred.

· Knowledge of ICD-9 and CPT coding guidelines for utilization review.

 

 

Physical Demands:

The physical demand described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

 

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, feel, talk, or hear. The vision requirements include: close vision, distant vision, peripheral vision, depth perception, and the ability to adjust focus.

 

 

 

Job Related Skills:

·  Communicate written and oral information accurately, timely and at the appropriate level to internal and external staff.

·  Ability to articulate clinical and non-clinical information to personnel of all levels of understanding.

·  Ability to communicate with team members in a positive manner.

·  Assist education of internal and external staff in operations, policies and procedures, and regulatory standards.

·  Ability to handle multiple tasks, set priorities, and develops action items.

·  Knowledge of regulatory requirements with emphasis on Medicare.

·  Detail oriented, excellent organizational skills, highly self-motivated and dependable.

·  Team and goal oriented.

·  Basic knowledge of mainframe/PC systems.

 

Please send resumes to conrad.hurt@healthspring.com