Performs admission, concurrent and retrospective quality and utilization review activities. Performs process improvement/utilization management monitoring for the medical staff. Analyzes data based on outcomes and prepares summaries. Assess and identifies patients' unique needs. Collaborates the discharge process with the physician and other members of the discharge planning team.
Minimum Job Requirements
Utilization Management or Case Management experience
Minimum 2 years clinical experience.
Registered Nurse, Licensed to practice in the State of Florida.
Essential Duties and Responsibilities
Conducts timely clinical reviews utilizing appropriate resources and critical thinking in applying nationally recognized criteria (Interqual or MCG) to support medical necessary level of care.
Performs concurrent and retrospective admission reviews.
Submits EQ Health criteria in a timely manner.
Collaborates and communicates with the Care Management Transition RN to determine continued patient centered clinical criteria and needs.
Addresses treatment delay, and potential and actual denials with the attending physician and members of the healthcare team.
Provides clinical reviews to third party payers and validates authorization or denial of services.
Collaborates with the Patient Access department to prevent denials based on inappropriate authorization for admission and with Authorization Specialists for continued admission authorization criteria.
Communicates with a variety of clinical disciplines and physician advisor to clarify and enforce criteria as identified and with outside reviewers on determination of their review.
Communicates with residents, attending physicians, and consultants regarding care transition issues.
Identifies potential delays and acts upon them to expedite discharge planning and level of care transition as identified.
Obtains needed orders from physicians for level-of-care changes as identified for each patient.
Immediately refers potential and actual denials to physician, physician advisor, utilization review leaders, Patient Access, & Patient Financial.
* Reports quality issues to Quality department as identified.
Communicates with payers and members of the healthcare team in a clear, timely, accurate, and professional format and manner.
Relays clinical information in a confidential manner per departmental policy & procedure and HIPAA guidelines.
Certification in Utilization Review or Case Management by a nationally recognized organization preferred.
Basic knowledge in use of computers and printers, and/or ability to learn appropriate software applications.
Good interpersonal skills and ability to establish a sound working relationship with Medical Staff and peers.
Pediatric background preferred.
Ability to communicate effectively, both verbally and in writing
Able to maintain confidentiality of sensitive information
Ability to interpret, adapt and react calmly under stressful conditions
Ability to use logical and scientific thinking to interpret technical data
Primary Location :
Florida-Miami-Nicklaus Children's Hospital - Main Hospital Campus
Nicklaus Children’s Health System, is the region’s only healthcare system exclusively for children. In addition to Nicklaus Children’s Hospital and a growing number of outpatient centers located throughout the tri-county area, the health system includes Nicklaus Children’s Hospital Foundation, the organization’s fundraising arm; Nicklaus Children's Pediatric Specialists, a nonprofit physician practice subsidiary; a management services organization, and an ambulatory surgery center. Our vision is to be where the children are. Ultimately, this means being there through all stages of health and life, both physically and emotionally. To be a trusted partner to children and their families, not only in times of illness, but throughout their life journey. Our mission is to inspire hope and promote lifelong health by providing the best care to every child.