OverviewDominican Hospital (a member of Dignity Health) is a 222-bed facility that offers a wide range of services to residents of California’s Central Coast. With 24/7 emergency care comprehensive care in cardiac orthopedics oncology women’s and children’s services we continue to lead the region in medical innovation and excellence in healthcare. Comprehensive CareDominican offers emergency services and is a Certified Stroke Center and Chest Pain Center. Dominican’s services include the only comprehensive Cancer Center in Santa Cruz County a Total Joint Replacement program and advanced neurological and endoscopic services. Dominican regularly receives ‘A’ grades for hospital safety from Leapfrog Group and has received national recognition for superior patient safety cardiac care and stroke treatment from Healthgrades a leading provider of comprehensive information about physicians and hospitals.As Santa Cruz County’s heart attack (STEMI) receiving center Dominican Hospital provides cutting edge cardiac care. The hospital’s heart attack treatment times consistently beat the national average and the hospital offers two cardiac catheterization labs available 24 hours a day 7 days a week. Groundbreaking cardiac procedures at Dominican include the Transcatheter Aortic Valve Replacement (TAVR) procedure which allows for heart valve replacement without opening a patient’s chest.Dominican Hospital has forged significant partnerships with area hospitals to bring exceptional care to Santa Cruz County. The hospital offers a level III Neonatal Intensive Care Unit (NICU) through a partnership with Lucile Packard Children’s Hospital Stanford. Neurosurgery at Dominican is also offered through a partnership with Stanford Health Care.ResponsibilitiesJob Summary / PurposeResponsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.Essential Key Job Responsibilities
Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.
Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
Collaborates with facility RN Care Coordinators to ensure progression of care.
Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
Communicates the need for proper notifications and education in alignment with status changes.
Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.
Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.
Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.
Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
Responsible for completing required education within established timeframes.
Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
Participates regularly in performance improvement teams and programs as necessary.
Summary:Incumbent will promote and protect CommonSpirit Health’s integrity, and understand and accept any consequences for failure to comply with the following:Incumbent will know and comply with applicable rules and regulations including applicable Federal health care program requirements, the CommonSpirit Health Standards of Conduct: Our Values in Action Reference Guide, and CommonSpirit Health policies and procedures. Incumbent will also comply with CommonSpirit Health’s Conflicts of Interest policy, completing the annual conflicts of interest disclosure as necessary, and promptly notify management and fully disclose at any time in which there is a potential for a conflict of interest.Incumbent will take responsibility for his/her actions, seek guidance for, and promptly report any suspected violation as provided in the Standards of Conduct and CommonSpirit Health policies and procedures. Incumbent will maintain the highest standards of business ethics and integrity, including representing CommonSpirit Health in a positive way, display honesty in all dealings, and ensure confidentiality of all proprietary and operational information in accordance with laws, regulations and policies. Incumbent will maintain the confidentiality and integrity of all patients’ Protected Health Information in accordance with HIPAA and HITECH regulations and CommonSpirit Health policies and procedures. Incumbent will maintain appropriate records and documentation pertinent to the client/patient/staff and department operation applicable to his/her role. Incumbent will complete all mandatory education on time, and will cooperate in investigation matters as requested.QualificationsMinimum QualificationsRequired Education and ExperienceRequired
Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
Preferred
Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
At least five (5) years of nursing experience.
Required Licensure and CertificationsRequired
RN license in the state(s) covered is required.
Preferred
Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred
Required Minimum Knowledge, Skills, Abilities and Training
BLS required within 3 months of hiring if located within hospital
Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.
Proficient in application of clinical guidelines (MCG/InterQual) preferred
Knowledge of managed care and payer environment preferred.
Must have critical thinking and problem-solving skills.
Collaborate effectively with multiple stakeholders
Professional communication skills.
Understand how utilization management and case management programs integrate.
Ability to work as a team player and assist other members of the team where needed.
Thrive in a fast paced, self-directed environment.
Knowledge of CMS standards and requirements.
Proficient in prioritizing work and delegating where indicated.
Highly organized with excellent time management skills.
Pay Range$73.97 - $95.69 /hourWe are an equal opportunity/affirmative action employer.