Dignity Health Medical Review RN Per Diem in RANCHO CORDOVA, California
Dignity Health, one of the nation’s largest health care systems, is a 21-state network of 9,000 physicians, 59,000 employees, and more than 400 care centers, including hospitals, urgent and occupational care, imaging centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. In FY15, Dignity Health provided $1.7 billion in charitable care and services. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.
Core Job Function:
Consistently applies the utilization review process as required by the Code of Federal Regulations including the use of the Dignity Health designated criteria for primary review. Incorporates into the utilization review process the ability to access and interpret clinical information against the designated review 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/performance benchmarks for the facility and Dignity Health.
Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required time frames
Review every admission and observation order for appropriateness based on InterQual criteria within the required time frames and follows the approved utilization review procedures if the patient status order is not consistent with the medical necessity assessment
Notifies admissions office of errors/changes in patient data including changes in physician orders/incorrect admission status designation
Documents insurance authorizations received in Midas
Coordinates internal and external services to avoid under or over utilization of resources.
Indicates the working DRG in MIDAS and other tools
Facilitates or participates in interdisciplinary team meetings
Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned
Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay
Refers cases to Physician Adviser according to policy and documents the referral
Initiates the appropriate letter (HINN: admission or continued stay, ABN) for any Medicare beneficiary if the outcome of the Physician Advisor secondary review indicates that the patient does not meet inpatient admission/observation status or continued stay medical necessity criteria
Completes, when assigned, the Dignity Health Care Management Rebill Log or other approved communication tools or processes related to billing appropriateness. The log communication includes PFS notification when the outcome of the Physician Advisor secondary review indicates that the patient does not meet admission medical necessity criteria or changes in patient status including the use of Condition Code 44
All patients presenting to the hospital from ALL points of entry will be assessed for medical necessity, appropriate status and level of care by an RN Case Manager at or before the time of inpatient admission or placement into Outpatient Observation status; payer authorization documented when required
Points of entry management
Cross train and provide coverage as needed to GSSJSA transfer center
Mission and Dignity Health Core Values:
Employees will perform their job in a manner consistent with demonstrate the Dignity Health core values of excellence, collaboration, dignity, justice and stewardship.
Dignity – Demonstrates respect and empathy for each patient’s and family’s privacy and unique needs
Excellence – Strives to perform at a high level in order to provide excellence in patient care.
Collaboration – Participates in hospital and / or community-based programs to provide support to those in need.
Stewardship - Performs daily duties with a responsible utilization of patient, hospital, and community resources
Justice - Works to ensure support, safety, care, and well being for all patients, families and co-workers, regardless of race, religion, gender, social/economic status or ability.
Professionalism, Quality, Growth and Safety:
Employees will conduct their job functions in a manner consistent with their professional licensure and will demonstrate willingness to learn, improve, grow and achieve.
Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
Effectively organizes work priorities.
Demonstrates compliance with facility and departmental safety and security policies and practices.
Educates hospital team members and physicians about the Case Manager role and scope of RN practice.
Supports the hospital quality, risk and performance improvement programs.
Keeps informed of local departmental policies and Dignity Health initiatives by attendance staff meetings and Dignity Health sponsored conference calls, meetings and events.
Demonstrates appropriate attendance per company policy and ensures that unscheduled absences do not exceed the Dignity Health or facility standard.
Provides proper notification of absences or tardiness within established standards.
Exhibits interpersonal, collaborative and team building qualities as well as awareness of one’s own behaviors and adjusts behavior and actions appropriately.
Adheres to all Dignity Health, Human Resources and Compliance Policies and Procedures.
Associate's degree in Nursing from an accredited school of nursing required
Current California RN license required
Three (3) years in acute care hospital experience required
Broad knowledge of medical and allied health sciences required
Demonstrated ability to measure screening criteria against the documented medical record required
Excellent written and verbal communication skills required
Bachelor's of Science in Nursing from an accredited school of nursing preferred
Recent utilization review experience preferred
One (1) or two (2) years of case management experience preferred
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Dignity Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected Veteran status or any other characteristic protected by law. For more information about your EEO rights as an applicant, please
If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this telephone number.
Job ID 2018-55594
Employment Type Per Diem
Department Care Coordination
Hours / Pay Period 24
Facility Corporate Service Center
Location RANCHO CORDOVA
Standard Hours Varied between 5pm-5:30am (1700-0530)