Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
PeaceHealth is seeking a RN Utilization Review/Case Management - Behavioral Health for a Per Diem/Relief, Day position. Hourly compensation starts at $39.62, more depending on experience.
Responsible for promoting effective utilization and monitoring of healthcare resources, along with medical case management of patients with chronic unstable conditions and patients who have been recently hospitalized. This position will assume a leadership role with the interdisciplinary team to achieve optimal clinical, financial, and satisfaction outcomes.
- Acts as intermediary between the hospital and third party payors to ensure patients receive appropriate medically necessary inpatient psychiatric and medical services, so that the organization receives appropriate and optimal reimbursement.
- Screens admission referrals in conjunction with the psychiatrist and through the filter of Behavioral Health Inpatient Unit’s admission criteria. Understands and adheres to Medicaid standards. Gathers all needed referral information to inform decision .Monitors accepted admissions from off hours and educates regarding admission criteria as needed.
- Ensures the best use of limited inpatient resources by confirming that accepted patients meet medical necessity criteria and will benefit from hospitalization.
- Communicates proactively and adeptly with members of the interdisciplinary team to ensure hospital and community resources are appropriately and effectively utilized on behalf of patients and their families.
- Collaborates closely with other departments such as Patient Financial Services, Health Records and Contracting to ensure efficient work process in obtaining authorizations, timely payment and proper billing in patient accounts.
- Guides discussion in treatment teams to improve quality, decrease cost and improve patient satisfaction. Communicates variance days to treatment team and to manager.
- Monitors all disciplines’ documentation to ensure it supports need for acute and ongoing psychiatric inpatient care in order to reduce denials. Ensures all disciplines document to Medicaid/ Medicare standards. Provides education and feedback to disciplines and/or individuals to standardize documentation.
- Works closely with Patient Financial Services to assist in decreasing denials.
- Maintains issue tracker related to third party denials and interfaces with management as needed to initiate investigation of denials.
- Maintains issue tracker related to CDMP issues and communicates medical co-morbidities to treatment team. Identifies and evaluates medical co-morbidities for billing purposes.
- Communicates adeptly and within designated time frames with third party payors in order to obtain authorizations and resolve payment issues on behalf of patients and families and the organization.
- Oversees and supports staff with wound care and patient education.
- Oversees and supports Electroconvulsive Therapy (ECT) process.
- Attends unit leadership meetings. Collaborates regarding unit issues and quality assurance. Provides staff education as appropriate.
- Performs medical case management, including patient education regarding chronic and complex medical conditions; monitors relevant lab values, obtains medical history, arranges medical follow-up appointment post-surgical procedures, orders medical home health, CPAP, RT etc.
- Provides professional nursing presence and oversight based on unit needs.
- Graduate of an accredited State Board of Nursing approved nursing program required
- Bachelor’s degree required or completed within one year of hire.
- Minimum of 3-5 years psychiatric clinical work required
- Working knowledge of psychiatric diagnostics required
- Third party reimbursement knowledge desirable
- Current RN licensure in state of practice required
- Willingness to work toward CPUR certification preferred
- Proficient use of computers including MS Office applications and other applicable software applications.
- Ability to develop strategies for staff and patient education
- Strong communication skills, both verbal and written
- Understanding of Medicaid/Medicare standards and requirements
- Must be able to work both independently and interdependently with staff and team members with limited supervision.
- Excellent problem solving and critical thinking skills
- Ability to maintain documentation systems of care and tracking of patients
- Ability to develop and maintain patient resources for education and referral
- Strong organizational and critical thinking skills
- Strong medical background and knowledge of critical care
RIVERBEND- PHYSICAL/COGNITIVE REQUIREMENTS:
- Work requires normal amounts of physical effort at least 66% of the time.
- Ability to lift objects weighing 25 lbs. or less.
- Work may require frequent exposure to conditions involving minor cold, heat, poor ventilation or sharp instruments such as syringes or lancets. Reasonably anticipated exposure to blood and body fluids once per month or more.
- Job duties frequently require intense concentration and attention to detail (34-65% of work time).
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For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.