Catholic Health Initiatives RN-Utilization Review in LEXINGTON, Kentucky

RN-Utilization Review



Field: RN

Requisition #: 2018-R0162366

Post Date: 6 days ago

Facility: Saint Joseph Hospital, Lexington, KY

Status: PRN

Position Summary: Responsible for Utilization Review for medical necessity and level of care for patients accessing services at St. Joseph Hospital and St. Joseph East, though the application of InterQual Criteria and other resources as necessary. Determines correct patient status and obtains order from admitting physician. Cooperates with outside vendor on Medicare/Medicaid Observation vs. Admission status . Communicates with commercial payers with demographic and clinical information as contract requires. Issues ABNs and HINNs as needed per CMS guidelines. Enters complete clinical and payer information into MIDAS system. Facilitates action plans regarding denial management for all payers. Performs other duties as instructed by Department Director and or Department Manager.

Requirements: Education, Credentials, Licenses: Minimal Qualifications: RN with AD in Nursing, with UR experience. Experience with InterQual and UR. Desired Qualifications: 3-5 years recent acute care experience, 1 year UR experience or Case Management in a hospital or commercial insurance setting. Must speak fluent English in order that the individual be able to take direction from management, physicians and external parties. Must be able to communicate adequately with patients, co-workers and physicians as necessary, understand and follow safety guidelines and understand the Associate Handbook and all hospital policies. Must have adequate computer skills.

Adequate conversational English is required in order that the individual be able to take direction from management, understand how to complete job tasks, communicate adequately with patients and co-workers as necessary, understand and follow safety guidelines, and understand the Associate Handbook and all hospital policies.

Working Relationships: The Utilization Review Staff is responsible to the Manager of Managed Care and does not supervise any employees. The position is in daily communication with the RN care coordinators, medical staff and payers, and must demonstrate effective communication skills.

Additional Responsibilities:

  • Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times

  • Adheres to and exhibits our core values: Reverence : Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us. Integrity : Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness. Compassion : Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community. Excellence : Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.

  • Maintains confidentiality and protects sensitive data at all times

  • Adheres to organizational and department specific safety standards and guidelines

  • Works collaboratively and supports efforts of team members

  • Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community

Catholic Health Initiatives and its organizations are Equal Opportunity Employers

Additional Information

  • Requisition ID: 2018-R0162366

  • Schedule: Part-time

About Us

Chances are, you’re here because you’re looking for a career offering greater opportunity, challenge and fulfillment. We’re confident you’ll find all three at CHI. As one of the nation’s largest nonprofit health systems, we offer a wealth of careers across more than 101 hospitals in 18 states. Our faith-based health system welcomes you to share in our mission of building healthier communities, whether as a surgeon in the operating room or an administrator in a conference room. When you work in a supportive environment with like-minded professionals, wonderful things happen. Learn More

Equal Opportunity Employment

Consistent with our Core Values, Catholic Health Initiatives employers are EEO/AA/M/F/Vets/Disabled Employers. Qualified applications will receive consideration for employement without regard to their race, color, religion, national origin, sex, sexual orientation, gender identification, protected veteran status, disabilitiy or any other legally protected characteristic. ​