Charlotte, NC, United States
Job ID: 6959
Job Family: Nursing
Status: Full Time
Shift Details: Regular
Department Name: 46521019843106-Utilization Review
Location: Charlotte - 501 Billingsley Rd
Assists and collaborates with multidisciplinary team in providing specific clinical information that meets expectations of third party payors; responsible for timely provision/flow of clinical information to/from third party payor and multidisciplinary team to ensure certification/approval of inpatient services. Provides clinical expertise/knowledge support to the payor specialists' and reviews clinical information prior to sending to payor as needed to ensure information meets acute clinical care guidelines as determined by Clinical Care Management.
• Identifies clinical, financial and psychosocial needs of patients/families and provides leadership and guidance to the multidisciplinary team to develop an individualized plan of care.
• Coordinates appeals when NC Medicaid cases are denied with the DHS Hearing Officer.
• Ensures that essential information and necessary forms are forwarded to the Medical Audit and Appeals Department of CHS.
• Performs admission and concurrent reviews.
• Applies clinical guidelines during Admission and Concurrent reviews and identifies potential third party denials. Works with multidisciplinary team to identify and implement alternative plans of care.
• Refers pertinent information to the Medical Director, and/or Service Director in a timely manner.
• Collaborates on a daily basis with the physician to plan and implement the medical and multidisciplinary plan of care, utilizing clinical pathways when appropriate and available.
• Works with team members and leadership to identify problem areas and implement resolutions.
• Develops and maintains accurate case records of assigned cases. Documents in the patient's medical record according to department and facility standards
Works in an office setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Requires frequent verbal and written communication in English. Intact sight and hearing with or without assistive devices is required.
Education, Experience and Certifications
Graduation from an accredited School of Nursing required; Bachelor’s Degree in Nursing preferred. NC RN licensure required. Related experience preferred. Basic Life Support for Healthcare Provider (BLS HCP) from AHA required.