As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The purpose of the Utilization Management Nurse is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient setting. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Responsible for providing timely referral determination by accurate:
Usage of the Milliman Care Guidelines
Identification of referrals to the medical director for review
Appropriate letter language and coding (denials, deferrals, modifications)
Appropriate selection of the preferred and contracted providers
Proper identification of eligibility and health plan benefits
Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
Responsible for maintaining compliance in turnaround time requirements as mandated by the TAT Standards
Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
Meets or exceeds production and quality metrics.
Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
Attend all mandatory meetings and training.
Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
All other job related duties as it relates to the job function or as delegated by the management team.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Two (2) years managed care experience in UM/CM Department, preferred
Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred
ICD-9 and CPT coding experience a plus
Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
Experience in EZ-CAP preferred
Medical Terminology preferred
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
Minimum Education: LVN
Preferred Education: BA or BS in Nursing
Minimum Experience: 3 to 5 years of acute care experience
2 Years Health Plan Utilization Review or equivalent
Preferred Experience: 5 years Health Plan Utilization Review
5 years Acute Care experience with 1 year ICU / ER
Include minimum certification required to perform the job.
Licensure must be current and unrestricted in the appropriate jurisdiction
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to work in sitting position, use computer and answer telephone
Ability to travel
Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Office Work Environment
Approximately 5% travel may be required
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2105023173
About Conifer Health Solutions
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.