RN Utilization Review Specialist BHS
St. Dominic is currently looking for a qualified individual for a Utilization Review Specialist position with our Behavioral Health Services Admissions & Intake Department.
- Graduate of an accredited state nursing program
- At least 3 years of experience in the field and at least 1 year in Utilization Review or Case Management.
Must be able to communicate with medical staff and members of the healthcare team in such a manner as to gain cooperation with regard to utilization review activities. Must have the ability to function independently.
Verifies insurance benefits when necessary and communicates this as necessary to those patients involved.
Conducts precertification reviews.
Performs initial review of patient records and communicates with third party payors the information necessary to certify the admission.
Performs continued stay reviews of patient records at intervals as specified by third party payors communicating with them information as necessary to certify the continuing stay.
Utilizes information from all members of the treatment team as indicated to assist in establishing medical necessity for treatment.
Communicates with physicians concerns about the admissions, services, or continued stay,
Records precertification and on-going certification in designated manner including the AS400 system with emphasis on input into the CNE notes.
Conducts follow-up of appeals in a timely manner and reports denials, appeals and status on a weekly basis to supervisor for weekly report to fiscal services.
Conducts follow-up of retrospective reviews in a timely manner and reports the date sent and results in weekly report to supervisor for report to fiscal services.
Spends only amount of time on nursing units as necessary to review documents on chart that are not on the computer systems.
Makes calls to third party payors as necessary from the privacy of office.
Audits medical records on an ongoing basis as a means to assess and measure clinical practice patterns with respect to appropriate utilization of services.
Audits medical records on an ongoing basis to identify appropriate measures to improve the delivery and utilization of patient care services.
Maintains daily log of review activities including appeals and retrospective reviews and submits these to supervisor on a daily or weekly basis as requested.
Cooperates with social services/counselors in referral of patients for discharge planning.
Cooperates with fiscal services to facilitate resolution of concerns involving reimbursement.
Reports unresolved problems to supervisor.
Conducts bill audits when necessary reporting results to supervisor, fiscal services, and if indicated, the patient / patient representative.
Follows chain of command as established for department and facility.
Is able to follow hospital and department specific policies and procedures and updates.
Carries out requests of supervisor as related to work group goals of department or the overall efficiency of the department.
Conducts self in manner to convey a positive sense of team cooperation.
Supports and interprets hospital's Christian mission, philosophy and objective.
Maintains confidentiality of patients and other pertinent information.
Enhances professional growth and development through participation in educational programs, current literature, inservice meetings, and workshops.
Attends meetings as required.
Represents behavioral health services to referral sources, community agencies, social services agencies and others as quested.
About St. Dominic’s:
St. Dominic’s is a 535-bed acute care hospital specializing in cancer treatment, women’s services, surgery, behavioral health programs and more. We believe that when you join St. Dominic’s as an employee, you join the St. Dominic’s family. Each employee is a valued member of the total care team whose ministry of Christian healing serves the individual needs of our patients. It’s the commitment of our employees that makes St. Dominic’s one of the leading healthcare providers in the southeast.
About Jackson, MS:
St. Dominic’s is located in Jackson, Mississippi which boasts various museums and parks as well as a coliseum that hosts events year round. Downtown is home to Jackson Convention Complex, Davis Planetarium and Thalia Mara Hall which presents concerts, ballets and operas. Ross Barnett Reservoir is available to the public for boating and fishing
Mississippi is known for long, sunny summers and short, temperate winters. A lower than average cost of living makes your dollar go farther. The Jackson metropolitan area is roughly halfway between Dallas, Texas and Atlanta, Georgia and is approximately a 3 hour drive from New Orleans, Louisiana and Memphis, Tennessee.