Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.
Summary:
Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge. The hours for this position will vary with work up to 40 hours per week.
Essential Duties:
Determine, if the patient is going to be admitted, and ensure appropriate documentation to validate the admission as an inpatient or to place in outpatient with observation services.Review medical records for appropriate indicators of the medical necessity for hospital care, and work with the healthcare team to ensure that medical necessity is clearly documented within the medical record.Educate physicians/healthcare team regarding appropriate documentation to support level of care using approved evidence based criteria as a guide.Document in the appropriate case management EMR the medical necessity information supporting the admission.UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers,discharge planners, etc.) in –person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient’s care.
Qualifications:
Required Education: Associates Degree in NursingPreferred Education: Bachelors Science Nursing or higherRequired Experience: At least 3 years previous nursing experience
Preferred Experience: 3 plus years Utilization review experienceRequired License/Registration/Certification: Licensed Practical Nurse or Licensed Registered Nurse
Preferred License/Registration/Certification: ACM or CCM CertificationComputer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.
Physical Demands:
In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below: