Thompson Health is seeking a full time experienced, dedicated RN for the role of UM/CDS Nurse. UR Medicine's Thompson Health is the premier healthcare provider in the Finger Lakes region. We recently received Magnet? designation from the American Nurses Credentialing Center for the third time. You will enjoy a competitive salary and generous benefits, free onsite parking, an excellent staffing model and a modern, high-tech environment.
UM/CDS Nurse Responsibilities: The integrated UM and CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness, expected risk of mortality and complexity of the patient by improving the quality of the providers' clinical documentation. This involves extensive record review, interaction with providers, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Management Program (CDMP) and Utilization Management process is a key role. Performs utilization review in accordance with all state mandated regulations while maintaining compliance with regulation changes affecting utilization management that ensures appropriate and cost-effective healthcare services to patients. Assesses the appropriateness and medical necessity of the treatment requests for utilization review on a prospective, concurrent, and retrospective basis. Reviews patient's records and evaluates patient progress. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct reviews and validates physician's orders, reports progress and unusual occurrences on patients. Collaborates with physician in determining appropriate admission status & subsequent changes. Provides review information to payers as requested. Performs retro-active reviews for assigned denials and monitors steps throughout denial process. Writes effective denial letters and informs appropriate departments of outcomes. Works with the Medical Staff, Case Management/Social Work, Clinical Quality, the interdisciplinary care team and a variety of administrative support departments to ensure quality patient outcomes through the appropriate utilization of hospital resources. Collects, analyzes and maintains data on the utilization of medical services and resources in order to identify trends and opportunities for improvement. Serves as primary internal and external contact for Utilization Management related issues. Assesses quality and clinical risk issues on a concurrent basis; report any recognized issue to the supervisor. Reports quality of care issues identified through the utilization review process according to established policies and procedures. Provides education to members of the medical staff and their offices, department leaders, and associates on Utilization Management principles including the use of InterQual & Milliman criteria, CMS's local and national coverage determinations, and the importance of clinical documentation. Actively participates in various committees and workgroups related to Utilization Management, Length of Stay Management and Observation services. Will collaborate and assist the manager in the deployment of a Quality and Safety model to integrate regulatory mandates into the point of care areas such as concurrent core measure abstraction and provide training for JC readiness resulting in sustained positive outcomes. Will assist the manager to organize and facilitates activities associated with quality, patient safety, performance improvement, and utilization management. Active participation in team meetings and education of staff in the Clinical Documentation Management Program (CDMP) and Utilization Management process is a key role Required Competencies: Demonstrated knowledge of Utilization Management principles including knowledge of various regulatory and payer specific requirements. Ensures the integrity of the clinical documentation supporting medical necessity, diagnosis related groups (DRG) and quality of care in the medical records. Exhibits a broad understanding of patient care delivery in different settings. Demonstrates skill in daily communication including effectively gathering and disseminating information, ability to leverage a highly integrated healthcare information system in order to automate workflow whenever possible. Demonstrates the ability to work independently, prioritize and practice capable and effective problem identification and resolution with sound decision making; the ability to develop and maintain collaborative working relationships with diverse disciplines; recommending and implementing continuous quality improvements. Actively guards the confidentiality of sensitive information including but not limited to the patients, staff and the health system. Develop and maintain a positive work atmosphere and support the overall team. Attends educational opportunities & keeps up to date with all required federal and state regulations. Lives the CARES values at all times.
Qualifications: ?Registered Nurse in NYS
* Education: ?A.A.S. in Nursing ?B.S. in Nursing or other Health related field preferred * Experience: ?Minimum 5 years ED/ICU/Critical Care experience ?Prefer Utilization Review or Clinical Documentation specialist experience ?Experience working with physicians in a collaborative supportive manner. ?Knowledgeable in use of nationally recognized criteria or willingness to learn ?Knowledgeable in various reimbursement methodologies and experienced in interpretation of payer contracts or willingness to learn ?Experience with computer applications including Microsoft Office, ?Preferred Experience in writing effective appeal letters Complexity of Duties: ?Performs a variety of duties requiring independent judgment and decision making based on individual circumstances within a framework of established policies and procedures. ?Keeps abreast of complex and changing regulatory environment in order to develop proactive internal responses involving numerous stakeholders. ?Effective management of denial / appeals with attention to detail and follow-up ?Issue HINN letters when appropriate / coordinate hospital transfers ?To track and trend length of stay, issues with avoidable days * Shared weekend on-call rotation.
Thompson Health is an EOE encouraging women, minorities, individuals with disabilities and veterans to apply
Associated topics: ambulatory, ccu, intensive, neonatal, psychatric, psychiatric, recovery, registered nurse, staff nurse, surgery
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.