Work Shift
Day
Scheduled Weekly Hours
40
Summary
This position supports Mercy's philosophy of patient centered care by ensuring hospital health care services are administered with quality, cost efficiency and within compliance as provided by Mercy Medical Center.
Job Description
Job Duties
- Reviews medical records initially and consistently throughout the hospital stay to ensure that the patient is placed in the right status at the right time.
- Collaborate with CDI to ensure that complete and accurate documentation in the medical record supports the patient’s diagnoses and level of care determination.
- Daily management of UM work queues demonstrating effective and efficient UM reviews, prior authorization, submission of clinical documentation to payors.
- Utilize excellent and timely verbal and written communication with medical providers and hospital staff.
- Utilize Utilization Management tools Interqual and MCG to assist with placement of the patient in the correct status throughout the hospital stay.
- Educates medical providers regarding length of stay and resource utilization in compliance with Medicare and Medicaid guidelines. Monitor GMLOS to align with Actual Length of Stay. Develop action plan for any misalignment.
- Ensure prior authorization for hospital admissions and procedures is obtained in a timely manner in compliance with payor guidelines.
- Enhance continuity and quality of care through improvement of utilization management.
- Adheres to all federal, state and Mercy Medical Center facility policies related to compliance with payor guidelines and regulations.
- Participates in meetings with medical providers and care coordination to discuss patient care utilization trends and improvement opportunities.
- Collaborate daily with Care Coordination and Social Work regarding discharge planning progress and extended lengths of stay.
- Support/partner with inpatient care coordination team to ensure that documentation reflects the specificity and severity of current patient conditions.
- Develop and implement denials management process related to inpatient denials including initiation of peer-to-peer discussions and appeals submission.
- Maintain inpatient denials data analytics process. Provide quarterly report regarding inpatient denials rates and process improvement to Utilization Management Committee.
- Provide ongoing education with healthcare providers regarding effective peer to peer discussion process for overturning inpatient denials.
- Participate in orientation, education for new providers regarding Utilization Management Process.
- Identify opportunities for cost reduction through claims review, identification of services that are not medically necessary, coding errors, and duplication of services.
- Identify and implement process improvement opportunities related to Utilization Management
- Maintain high level, detail-oriented, quality performance of Utilization Management process to ensure optimal patient care and resource utilization throughout each hospital stay.
- Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.
Knowledge, Skills and Abilities
- Proficient in Microsoft Office products.
- Proficient in operation of computer, calculator, filing systems, copy/fax machines and telephone system.
- Excellent interpersonal skills.
- Excellent written and verbal communication skills.
- Excellent public relations and human relations - exemplifies The Mercy Touch.
- Excellent organizational and time management skills.
- Critical thinking, problem solving, and attention to detail skills.
- Exhibits good judgement.
- Handles confidential information with discretion and diplomacy.
- Commitment to life-long learning, e.g. willingness to learn/upgrade skills related to duties.
- Flexibility and dependability, works well with a wide variety of individuals and leadership styles.
- Ability to work with minimal to no supervision.
- Knowledge of Medicare Part A.
- Familiar with Medicare Part B.
- Knowledge of regulatory environment.
- Understand and communicate differences between Medicare Part A and Part B Guidelines.
Professional Experience
- Required:
- Minimum two years acute care or equivalent clinical setting experience
- Preferred:
- Experience in Case Management/Care Coordination and Utilization Review
Education
- Required:
- Associate degree in Nursing
- Preferred:
- Bachelor of Science in Nursing or other health related degree
Licensure, Certification, Registration
- Required: Maintain current Registered Nurse licensure in the State of Iowa
- Required: Basic Cardiac Life Support Certification with American Heart Association
- Preferred: Certification in Utilization Management, (required within one year of employment)
Pay Rate Type
Salary
Mercy is an independent, community-based organization supporting the Cedar Rapids area for over 120 years.
Mercy is an equal-opportunity employer. We value diversity, equity, and inclusion and therefore evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status, and other legally protected characteristics.