Assists with facility Administrators to implement and/or maintain a program to include a process for medical record reviews, reporting to third party payer sources, and measuring effectiveness of the process. Meets facility needs as demonstrated by facility's utilization of resources by timely, accurate and correct billing and payment for services. Knowledge of state, federal, and commercial payer source participation requirements. Participates as a member of the Clinical Advisory Committee; participates as a member of the UR Committee. Assists the facility in analysis of data to evaluate the effectiveness of processes in place for pre-certification, concurrent reviews, and retrospective reviews. Assists in development of utilization management process, provider and staff education of the process and accurate data submission. Manages RAC and MAC audit process
RN in State of Texas with minimum of 2 years clinical experience in an acute care hospital setting.
Required 1-2 years of utilization review and case management experience in hospital setting.
Working knowledge of the principles and theories of health care delivery. Considerable knowledge of Joint Commission, State, and Federal standards/requirements.
Excellent communication skills including a high degree of professionalism and personal presence. Ability to maintain effective working relationships with medical staff, managers, supervisors, other hospital employees and the public.
Computer experience required with skills including but not limited to Windows, spreadsheets, and word processing. Millimen background preferred.
Houston's Physicians' Hospital - 17 months ago