Registered Nurse uses approved screening criteria (Milliman/Interqual/CMS Inpatient List) to determine the medical necessity of a requested hospitalization and the appropriate level of care for that patient. Works collaboratively with Nursing Supervisor for appropriate bed assignment. Actively involved in management of inpatient observation patients. Provides consultative role as utilization management nurse to clinical and non-clinical departments. Documents objective findings against approved indicators. Assists with retrospective reviews and medical necessity denials per communication with third party payors. Follows UM policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC.
EDUCATION: Graduate of an approved school of nursing, BSN preferred.
CERTIFICATION/LICENSES: Current licensure as an RN in New Mexico mandatory.
SKILLS: Excellent reading, writing, and editing skills in English. Strong organizational skills. Knowledge of or ability to learn Milliman and Interqual criteria. Ability to effectively evaluate physician orders and medical records. Competent computer skills for word processing, data collection and retrieval. Ability to analyze and create reports.
EXPERIENCE: Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in an acute care setting. Experience with utilization management, knowledge of Milliman and Interqual criteria, managed care language, and CMS rules and regulations preferred.
NATURE OF SUPERVISION:
-Responsible to: Director and Manager of Case Management
ENVIRONMENT: Blood borne Pathogens: A
Office setting. Rotating shifts and weekends when necessary. Must be able to adjust to frequently changing workloads and frequent interruptions.
Ability to move around the hospital to all units/departments for about 10% of the day, in office 90% of the day. Requires close work, good vision, dexterity to write as well as to use computer keyboard. May be required to lift, push, pull and/or carry up to 25 lbs.
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and performance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, theref...ore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.