Case Coordinator/Utilization Review Nurse
FirstHealth of the Carolinas 18 reviews - Pinehurst, NC

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Bachelor’s Degree in Nursing with a minimum of 3 years nursing experience in medical/surgical, critical care and/or hospice, home health or public health required or Associate Degree in Nursing with a minimum of 4 years experience in medical/surgical, critical care and/or hospice, home health or public health required. Masters Degree in Nursing or related field preferred. Case Management/CPHM certification preferred.

Reviews charts for medical necessity and ensuring that patient’s are in the appropriate status/level of care. Includes initial assessment and continued stay review using the criteria as approved by the Utilization Management committee. Submits clinicals to payors per protocol and responds to requests for additional information within same business day. Reviews all tasks daily for follow up of assignment. Tracks avoidable days on all patients as indicated. Assists staff in clinical decision-making and priority setting to ensure an optimal length of stay. Collaborates with: admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of efforts and activities. Utilizes approved departmental communication tools for documentation. Provides consultation regarding the criteria used by the hospital when requested. Refers patients who do not meet criteria to second physician advisor for second tier review. Provides Observation notices for those Medicare Recipients as appropriate.

Participates in the overall delivery of any HINNs per policy/procedure. Collaborates with business office staff to assure accurate billing. Reviews all denials and prepares appeal within one business day. Confer when indicated with Director in guidance on how to pursue.

About this company
18 reviews
FirstHealth of the Carolinas maintains a health care network that spans across 15 counties in the mid-Carolinas. The network includes three...