Coordinator-RN Utilization

Essential Functions
Coordinates:

• Consults with physician services
• Utilizes clinical diagnostics, physician documentation and non-physician clinical guidelines to facilitate status determination of inpatient, outpatient or outpatient observation.
• Coordinates final status with admitting and attending physicians
• Performs initial and concurrent clinical reviews as indicated by payer and patient clinical needs
• Inpatient and/or outpatient notification and precertification of services to payers
• Facilitates peer to peer, written reconsiderations or appeals throughout all denial cycle as appropriate
• Facilitates appropriate observation utilization
• Consults with patient financial services
  Educations:
• Provides education and literature to physician services regarding IPPS and OPPS
• Educates physicians and other care team member on level of care criteria and other third party payer requirements
  Reporting/Recordkeeping:
• Updates patient’s medical records as required
• Shares medical necessity documentation with payers to facilitate reimbursement
  Regulation :
• Adheres to NMHS/NMMC Policies/Procedures/Guidelines
• Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues
  Requirements:
• Associates Degree in Nursing, required; Bachelor’s Degree preferred
• Licensed as a Registered Nurse by the Mississippi Board of Nursing; required
• Minimum of 5 years clinical and/or healthcare experience; required
• Excellent organizational and communication (written and verbal) skills;  required
• Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required
• Certified as an Accredited Case Manager (ACM); desirable
• Excellent interpersonal skills; required
• Demonstrates ability to care for a patient population from pediatric to geriatric; required