Utilization Review Registered Nurse, Behavioral Health
Company: St. Luke's University Health Network
Location: Allentown
Posted on: January 12, 2021
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Job Description:
St. Luke's is proud of the skills, experience and compassion of
its employees. The employees of St. Luke's are our most valuable
asset! Individually and together, our employees are dedicated to
satisfying the mission of our organization which is an unwavering
commitment to excellence as we care for the sick and injured;
educate physicians, nurses and other health care providers; and
improve access to care in the communities we serve, regardless of a
patient's ability to pay for health care.The Utilization Review
Nurse will be responsible for substantiating medical necessity and
clinical appropriateness of services in order to achieve quality
outcomes and ensure appropriate reimbursement. JOB DUTIES AND
RESPONSIBILITIES:* Screens selected medical records in accordance
with contractual agreements and departmental policies for
appropriateness of admission; performing initial, continued stay,
and retrospective reviews if applicable.* Submits initial reviews
and updates using established criteria and communicates with payers
as appropriate, using established processes.* Utilize established
processes to manage second level and peer to peer reviews.* Ensure
patient status and levels of care are appropriate on admission and
prior to discharge.* Makes timely contact with payers and provides
information as appropriate.* Documents all utilization review
outcomes and activities appropriately in the medical record.*
Complies with all applicable payer, state and federal regulations
as well as The Joint Commission requirements regarding Care
Management and Utilization Review processes.* Acts as resource for
and provides updates to the care management staff and care team for
issues related to utilization review processes.* Engages providers
with concerns regarding medical necessity and appropriateness of
services.* Escalate concerns related to medical necessity and
appropriateness of services.* appeals and documents according to
established policy.* Works collaboratively with the business
office/finance to ensure proper reimbursement.PHYSICAL AND SENSORY
REQUIREMENTS: Sitting for one to two hours at a time. Standing for
up to 2 hours per day, up to 10 minutes at a time. Walk on all
surfaces for up to 3 hours per day, and climb stairs. Must be
capable of driving a car. Fingering and handling objects
frequently, uses fingers to turn pages. Frequently uses hands to
write and/or type. Rarely uses hands or fingers for firm grasping
or twisting/turning. Frequently uses upper extremities to lift and
carry object up to 10 lbs. Rarely may be required to lift, carry,
push, and/or pull objects weighing up to 75 pounds. Occasionally
stoops, bends, squats, kneels and reaches above shoulder level.
Must have the ability to hear as it relates to normal conversations
and high and low frequencies and to see as it relates to general
and peripheral vision. Must have the ability to touch as related to
telephone and computer keyboard.EDUCATION: Graduate of professional
nursing program. Registered Nurse with current license to practice
in the State of Pennsylvania or seeking Pennsylvania licensure
through reciprocity. Advanced degree preferred. TRAINING AND
EXPERIENCE: At least 3 years of clinical experience as a registered
nurse in an acute setting; Behavioral Health preferred. Either 2
years of hospital or payor based utilization review experience
preferred. Knowledge of Interqual and Milliman criteria preferred.
Care Management certification preferred.WORK SCHEDULE: Monday thru
Friday, primarily days. Flexibility may be required to meet unit
needs.Please complete your application using your full legal name
and--current home address. Be sure to--include--employment history
for--the past seven (7) years, including your present employer.
Additionally, you are--encouraged to upload a current resume,
including all work history, education, and/or certifications
and--licenses, if applicable. It is highly recommended that you
create a profile at the conclusion of submitting your first
application. Thank you for your interest in St. Luke's!!St. Luke's
University Health Network is an Equal Opportunity Employer.
Keywords: St. Luke's University Health Network, Allentown , Utilization Review Registered Nurse, Behavioral Health, Other , Allentown, Pennsylvania
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