Job Location : Ashland,WI, USA
Category:
Ashland Medical Center
Department:
Quality
Schedule:
FTE: 0.9 Full-Time
About the Job:
Demonstrates a high degree of accuracy and attention to detail in conducting utilization review studies to evaluate the appropriateness of admissions to the hospital, observation assignments, lengths of stay, discharge practices, use of medical and hospital services, and all related factors that may contribute to the effective utilization of hospital services.
* Conduct medical certification review for medical necessity for acute care facility and services.
* Use nationally recognized, evidence-based guidelines approved by medical staff in conjunction with medical documentation to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities.
* Reviews utilization review activities for occurrences and trends that affect the quality, cost effectiveness, and delivery of services and assures the outcome of the review is appropriately documented and maintained in the applicable databases and record systems.
* Submit authorizations for admission and continued stay via email/fax and insurance portals to Medicare and Medicaid, Health Maintenance Organizations (HMOs) and private insurers per payor requirements.
* Maintain oversight by tracking metrics and generating reporting on usage patterns for medical necessity and appropriateness of care against screening criteria and denials.
* Collect and prepare documentation and collaborate with physicians as needed for a peer-to-peer review to resolve appeals and grievances.
Requirements:
* At least two years of nursing experience with licensure, or eligible for certification and/or licensure, as a Licensed Practical Nurse (LPN) in the state. A healthcare-related associates degree or two-year program certificate is preferred. Proficient in applying care criteria (e.g., InterQual Level of Care Criteria or MCG) and knowledgeable of local and national coverage determinations and documentation thereof in Electronic Medical Record systems based on experience or obtained within three months of hire.
* Proficient in necessary computer skills (e.g., clinical documentation in Epic, InterQual, insurance portals, and Microsoft Excel and Word) within three months of hire.
* Recent work experience in the hospital, hospital revenue cycle, or insurance settings preferred.
* Regularly participates in ongoing continuing education related to role.
Benefits and Salary:
Commensurate with position and experience. Comprehensive benefits package to include: medical, HSA, dental, 403(b) with employer match of 5%, PTO, wellness benefits, etc.
About Us:
AMC is a regional medical center that serves patients from 7 counties in northwest Wisconsin and Gogebic County in Michigan. We have more than 70 full-time physicians and specialists on-staff and over 600 employees who are dedicated to providing quality care. Our charming city of Ashland, WI is located on the shores of Lake Superior near Bayfield and the 21 Apostle Islands, and boasts a strong community, historic charm, modern conveniences and abundant opportunities for outdoor recreation. Our passion and driving force is to see the people of our community live healthy, productive lives.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.