Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.

This position comprehensively conducts pre-certification reviews as well as initial clinical and continued stay reviews to ensure appropriateness of treatment setting and compliance with payer guidelines and member benefits.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Registered Professional Nurses, or appropriate state board where services will be provided, as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Three years clinical experience in a hospital setting required.

PREFERRED QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Nursing preferred.

EXPERIENCE:

1. Prior Care Management experience preferred.

2. Prior experience with InterQual and/or MCG Criteria.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Collaborates with all members of the multidisciplinary team to facilitate the appropriate level of care for the designated caseload.

2. Monitors the patient’s progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.

3. Provides education as needed to staff, physicians, and patients and their families with regard to payer guidelines and benefit limitations.

4. Collaborates with the Medical Director or designee within the guidelines outlined in the Utilization Review Plan.

5. Communicates all necessary information regarding denials to the Care Management team and Physician in a timely manner.

6. Provides timely and comprehensive documentation of clinical reviews according to payer guidelines and departmental procedures.

7. Working knowledge of patient’s current medical insurance coverage and limitations including precertification requirements.

8. Collaborate for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination

9. Uses quality screens in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions

10. Responsible for completion of all clinical reviews for patients admitted and discharged to WVU Medicine, including patients admitted and discharged over the weekend

11. Consistently and accurately applies approved utilization criteria to ensure medical necessity of patient’s admissions and continued stays, along with identified testing when applicable (MRI’s) and documents the findings based on department standards,and procedure.

12. Screens for appropriate authorization and level of care for admission to WVU Medicine Same Day Surgery and IP Surgery suite.

13. Communicates with Payer Specialists and /orpayors to facilitate covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (. Peer to Peer) and follows up to resolve problems with payors as needed.

14. Educates hospital staff and physicians to payer regulations and managed care principals to prevent denials.

15. Fosters the integration of staff and/or students into the healthcare team.

16. Exhibits professional behavior on a consistent basis.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged walking, standing, or sitting may be required.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Required on call and weekend/holiday rotations as needed.

SKILLS AND ABILITIES:

1. Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.

2. Ability to work with people of all social, economic, and cultural backgrounds and be flexible, open minded, and adaptable to change.

3. Capable of independent judgment and action regarding psychosocial needs of patients.