at Ann & Robert H. Lurie Children's Hospital of Chica in Lake Forest, Illinois, United States
Job Description
Ann & Robert H. Lurie Children's Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children's Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report.
LocationAnn & Robert H. Lurie Children's Hospital of Chicago
Consistently applies the utilization management process as required by the Code of Federal Regulations, including the use InterQual Evidenced Based Medical Necessity criteria for primary review. Incorporates into the utilization management process the ability to access and interpret clinical information against InterQual Evidenced Based Medical Necessity criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial and performance benchmarks. The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, and other Federal or State regulatory agency requirements specific to Utilization Review.
Job Description
1. Communicates with Admitting or PFS regarding the needs of the patient, payer and provider.
2. Communicates relevant elements of the patient's health plan benefits.
3. Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required timeframes.
4. Reviews every inpatient admission and observation order for appropriateness based on InterQual Evidenced Based criteria within the required timeframes and follows the approved utilization review procedures if the patient status order is not consistent with the medical necessity assessment.
5. Notifies Admitting Department of errors or needed changes in patient data including changes in physician orders/incorrect admission status designation.
6. Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned.
7. Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay.
8. Refers cases to the Case Management leadership and/or Case Management Medical Director as needed and documents the referral.
9. Provides and documents concurrent reviews or other information requested by the payer within required timeframes.
10. Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
11. Demonstrates compliance with facility and departmental safety and security policies and practices.
12. Educates hospital team members and physicians about the Utilization Management RN and scope of practice.
13. Supports the hospital quality, risk and performance improvement programs.
14. Other job functions as assigned.
Minimum Qualifications:
BSN
2 year minimum of RN practice exp.
License to practice as a RN in the state of Illinois
Education
Benefit Statement
For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:
Medical, dental and vision insurance
Employer paid group term life and disability
Employer contribution toward Health Savings Account
Flexible Spending Accounts
Paid Time Off (PTO), Paid Holidays and Paid Parental Leave
403(b) with a 5% employer match
Various voluntary benefits:
Supplemental Life, AD&D and Disability
Critical Illness, Accident and Hospital Indemnity coverage
Tuition assistance
Student loan servicing and support
Adoption benefits
Backup Childcare and Eldercare
Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
Discount on services at Lurie Children's facilities
Discount purchasing program
Lurie Children's and its affiliatesare equal employment opportunity employers. We value diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity or expression, religion, national origin, ancestry, age, disability, marital status, pregnancy, protected veteran status, order of protection status, protected... For full info follow application link.
EEO/AA Employer/Vets/Disability
