Registered Nurse uses approved screening criteria (Milliman®/Interqual®/CMS Inpatient List) to determine the medical necessity of a requested hospitalization and the appropriate level of care for that patient. Provides consultative role as utilization management nurse and discharge planner to clinical and non-clinical departments. Documents objective findings against approved indicators. Assists with retrospective reviews and medical necessity denials per communication with third party payors. Communicates and negotiates appropriate length of stay and obtains prior and continuing authorizations with managed care providers and third party payers. Provides assistance to patients and families through evaluation of social, emotional, and financial needs and coordinates appropriate resources to ensure continuity of care across the behavioral health continuum through discharge planning and utilization review functions. Follows UM policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC.
EDUCATION: Graduate of an approved school of nursing, BSN preferred.
CERTIFICATION/LICENSES: Current licensure as an RN in New Mexico required. Current CPI certification required.
SKILLS: Excellent reading, writing, and editing skills in English. Strong organizational skills. Knowledge of or ability to learn Milliman® and Interqual® criteria. Ability to effectively evaluate physician orders and medical records. Competent computer skills for word processing, data collection, and retrieval. Ability to analyze and create reports.
EXPERIENCE: Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in an acute behavioral health setting. Experience with utilization management, knowledge of Milliman ®and Interqual® criteria, managed care language, and CMS rules and regulations preferred.Experience with case management / discharge planning and resources.
NATURE OF SUPERVISION:
-Responsible to: Manager of Behavioral Health Unit
ENVIRONMENT: Blood borne Pathogens: A
Office setting. Rotating shifts and weekends when necessary. Must be able to adjust to frequently changing workloads and frequent interruptions.
Ability to move around the hospital to all units/departments for about 10% of the day, in office 90% of the day. Requires close work, good vision, dexterity to write as well as to use computer keyboard. May be required to lift, push, pull and/or carry up to 25 lbs.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.