OverviewUSA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
ResponsibilitiesCoordinates the concurrent utilization review program for all payors; develops and implements a structured orientation program for new Case Management Specialists (CMS); orients new CMS on utilization management documentation specific software, criteria application, other applicable programs and workflow; monitors new CMS progress throughout orientation time period and provides annual, expert-level education for CMS regarding updates and trends utilizing review criteria for all payors; obtains knowledge sufficient to function as the trainer; and maintains knowledge base to function as a superuser of the utilization management documentation system; functions as an expert resource for case management specialists; analyzes all assigned payor cases through secondary reviews, evaluating for appropriate application of criteria and patient billing type in order to maximize reimbursement potential; monitors compliance with HINN letter (eg., Code 44 and MOON) processes for Medicare patients, and educates as appropriate; facilitates decision making related to and delivery of non-covered days/services letters during appropriate time frames; develops and monitors physician advisor/secondary review process including utilization, outcomes, expenses, and provider specific data; synthesizes data obtained during secondary reviews to identify staff educational needs; communicates effectively with care management staff to ensure all educational needs are met; communicates effectively with physicians, nurse managers and nursing staff as needed to ensure appropriate severity of illness and intensity of service documentation is present in medical record to support medical necessity decisions; communicates with billing staff to ensure application of appropriate patient stay type during billing process; develops and maintains expert level understanding of payor specific (eg., Centers for Medicare and Medicaid Services, Blue Cross) regulations on all things related to the specific payor programs including but not limited to stay types, documentation, claims, audits, and appeals; coordinates all revenue cycle audit activities within time frames to maximize financial potential; completes retro reviews on patient records where insurance information is added 30 days post discharge; performs appeals and denials research and communicates with physician, CMS, and payor to ensure all avenues of appeals are timely and accurately utilized; evaluates insurance correspondence/faxes for issues related to stay types, non-compliance with clinical review deadlines, and submission of appropriate clinical information; maintains direct CMS competency functioning as CMS if needed secondary to staffing/census; liaises with outside agency staff to create and maintain working relationships in support of essential functions; develops, implements, and monitors appropriate utilization management quality indicators; analyzes data derived from utilization management quality indicator monitoring for physician specific patterns or trends; functions as person in charge in the absence of the Director and/or Assistant Director; communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone; responds to overhead pages; accepts and completes all duties positively and without conflict; cooperates, helps others and improves the performance of the department; abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values; adheres to hospital policies including confidentiality; completes all mandatory department, educational and hospital requirements; enhances professional growth and development through participation in education programs; utilizes cost effective practices in performing all aspects of the job; maintains orderliness and cleanliness of work areas, equipment and supply areas; adheres to current Infection Control and Safety Standards; functions as team player and leader in cooperative spirit inter- and intra-departmentally; maintains expert application knowledge of pediatric and adult medical necessity criteria sets; requires minimal supervision to safely perform functions; utilizes proper body mechanics when moving equipment/supplies necessary to perform essential functions; participates on committees as assigned; participates in Performance Improvement activities as assigned; regular and prompt attendance; ability to work schedule as defined and additional hours, weekends, and call as required; related duties as required.
QualificationsBachelor's degree in nursing from an accredited institution as approved and accepted by the University of South Alabama, three years of utilization review, case management or related experiences, and current licensure with the state of Alabama as a registered nurse.
Accredited Case Manager or Certified Case Manager certification and master's degree in nursing are preferred
Equal Employment Opportunity/Affirmative Action EmployerUSA Health is an EO/AA employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status or any other applicable legally-protected basis.
