Description

The Legacy nursing philosophy focuses on patients and their families. Our nurses embody this philosophy in everything they do, as advocates, communicators, problem-solvers and caregivers. Their expertise is sought after and respected by our health care team. In short, they are the face of wellness at Legacy. Does this sound like an environment in which you could thrive? If so, we invite you to consider this opportunity.

Serves as the interdisciplinary team expert and consultant regarding appropriate classification determinations.  Ensures adherence to medical necessity criteria, regulatory requirements, and insurance rules.  Acts as the primary status dispute prevention agent by performing admission and continued stay reviews as per government and commercial payor contractual requirements, to include the JCAHO Utilization Review Standard. Responsible for timely provision and flow of clinical information to and from third party payors and Care Management staff to ensure authorization of hospital services.  Collaborates with the healthcare team, as well as Compliance and Revenue Cycle partners, on issues related to:  continued stay, avoidable days, readmissions, RAC denials, second level reviews, outlier issues, and denials management.  Serves as a contributing member of the Utilization Management Committee.

Education:

• Academic degree in nursing (BSN or MSN/MN) required; MSN/MN preferred.

Experience:

• This position requires extensive knowledge of diseases, procedures, treatments, prognosis, medical necessity requirements and healthcare reimbursement. Minimum 2 years of acute care nursing required.  Relevant experience in one or more of the following areas preferred:
  • Utilization Management
  • Care coordination of diverse patient populations
  • Knowledge of levels of care throughout the health care continuum
  • Denials prevention and management
  • Utilization of Cortex (XSOLIS) platform

Knowledge/Skills:

• Excellent organization, oral and written communication skills for effective interaction with patients, physicians, health care team members and representatives from insurance plans.
• Proficient statistical analytical skills for application of medical necessity criteria to patient stays and review of trends within healthcare.
• Knowledge of transition planning, health care reimbursement and utilization management processes.
• Knowledge of specific criteria and CMS guidelines for authorizations of continued inpatient stay or provision of outpatient services.
• Knowledge of regulatory issues.  Ability to adhere to and implement regulations in an effective manner.  Serve as a resource to all team members regarding regulatory issues.
• Keyboard skills and ability to navigate electronic systems applicable to job functions.

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