This position is responsible for analyzing clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Is responsible for clinical review of all requested services for appropriateness based on clinical criteria. Performs selected member calls to address post hospital discharge services, ongoing durable medical equipment usage and other telephonic follow up identified by UM/CM Management. This position will facilitate with negotiations for out of network care.
Proactively analyze information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards and within governmental and contractual guidelines
Identify and present cases of possible quality deviation, questionable admissions and prolonged length of stay to the Medical Director for further determination
Collects accurate data for the system input by using correct coding of diagnosis and/or procedures.
Processes authorization requests via phone queue according to internal departmental processes
Performs selected member calls to address post hospital discharge services, ongoing durable medical equipment usage, and other telephonic follow up identified by UM/CM Management.
Establishes and maintains rapport with providers as well as ongoing education of providers concerning appropriate protocol
Collaborates and maintain open communications with all other departments as appropriate and required to facilitate completion of tasks/goals.
Facilitate negotiations for out of network care
Collaborate with all other departments as appropriate and required to facilitate the completion of tasks/goals
Maintain quality documentation of collected data, actions take, and results of actions taken in order to promote continuity of care within governmental and contractual requirements
Self-starter with ability to handle multiple projects at one time
Demonstrates organizational, time management, prioritization and team work skills
Follows the CHRISTUS Guidelines related the Health Insurance Portability and Accountability ACT ( HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Communication, Collaboration, and Coordination with customers, internal and external
Present and/or facilitate one departmental in-service per calendar year
Attend monthly departmental staff meetings and/or interdepartmental meetings as appropriate
Analytic ability to prepare status reports and document procedures
Excellent communications skills, judgment, initiative, critical thinking and problem solving abilities
Ability to handle and resolve complex issues
Ability to work occasional long or irregular hours
Ability to work a flexible work schedule.
Graduate of an accredited Registered Nursing Program, Bachelor Degree preferred
Basic Knowledge of computer systems
Good typing skills
Excellent customer service skills
Excellent negotiation skills
Minimum of three years diverse clinical experience as RN
Minimum of two years case management and/or utilization review experience
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.