Utilization Review Coordinator
La Rabida Children's Hospital

Chicago, Illinois

This job has expired.


Job Details

Who we are:

La Rabida Children's Hospital is the only hospital of its kind in Chicago. As an acute care specialty hospital, we focus on treating those with complex medical conditions, chronic illnesses, developmental disabilities, abuse and trauma. La Rabida is a place unlike any other. We understand the needs of families with children battling the most serious or complicated of conditions. With teams of the best healthcare providers in Chicago, we give continuous, comprehensive care, education and support, helping families face their unique obstacles head on.

La Rabida offers rewarding job opportunities across a wide array of clinical, administrative and support service functions. If you're ready to work for an organization where caring is a way of life, you've come to the right place. Oh, and the lakefront views are spectacular too!

Job Description & Responsibilites:

  • Works with Admitting and Case Management staff to ensure that insurance verifications and pre-admission approvals are obtained from third party payers as needed, including the identified state Peer Review Organization.
  • Interacts with health care providers to identify medical necessity and appropriateness of admission to the inpatient setting and provides feedback to staff on appropriate documentation to support the need for admission.
  • Completes initial and concurrent reviews on open inpatient charts and communicates clinical information to third party payers for approvals. Educates physicians and other staff on documentation standards to proactively prevent denials. Takes action to facilitate discharge or transfer when established criteria for inpatient stays are not met.
  • Coordinates all requests for information from external review agencies to facilitate reimbursement. Serves as hospital liaison/contact for the state identified Peer Review Organization. Reviews all charts for completeness prior to review by the PRO.
  • Initiates expedited appeals on denials by coordinating with the health care team to obtain required information. Coordinates the appeal process related to denial of payments or potential/identified quality of care issues.
  • Refers cases and issues to the physician advisor for Utilization Review as needed. Follows up on the cases until resolution is reached.
  • Reviews the hospital Utilization Management program biannually and updates it as needed (in collaboration with the Utilization Review physician and Patient Care Leadership).
  • Works with Patient Financial Services as the clinical liaison to advise and resolve any billing issues.
  • Functions as a resource to other hospital departments as a resource on Utilization Review issues.
  • Provides education to physicians and other staff on topics related to Utilization Review and related standards, such as JCAHO and HCFA.
  • Prepares monthly reports on appropriate utilization statistics (such as length of stay and denials)

  • COMPETENCY ASSESSMENTS:

    Maintains required job skills, professional competencies, current licensure, certification and ongoing education required of job, as applicable.

    Supports the hospital mission, and observes hospital core job values with respect to Service Excellence Standards, work quality, productivity, teamwork and initiative.

    Demonstrates safe and proper usage of machinery/equipment, as applicable.

    Demonstrates additional departmental specific areas of competencies as defined annually.

    Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served in their area.

    Demonstrates knowledge of the principles of growth and development over the life span.

    Demonstrates ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to their specific needs.

    Demonstrates ability to provide the patient care needed as described by the hospital.

    Attends Mandatory Education Sessions:
    • Annual Infection Control
    • Annual Safety
    • Disaster
    • Hazardous Wastes & Material
    • Others as determined by Hospital and Department
    Demonstrates knowledge and behaviors regarding:
    • Hospital Infection Control Program
    • Hospital Safety and Risk Management Program
    • Hospital Hazardous Waste & Material Plan
    • Departmental Specific Safety Policies
    • Patient Rights and Cultural Diversity
    • Confidentiality
    • Hospital Mission and Goals
    • Hospital CQI/QM Program
    • Service Excellence Standards
    • Department Policy and Procedure Manual
    • Employee Handbook
    Job Requirements:

    Education:
    • Graduation from an accredited nursing program
    Related Work Experience:
    • Minimum of 3 years in inpatient nursing, pediatrics preferred
    • Experience in Utilization Management required
    Licensure/Certification:
    • Current Illinois license as a Registered Nurse
    Specialized Knowledge and Skills:
    • Must have knowledge of governmental and accrediting agency requirements and knowledge of managed care (HMO and PPO)
    • Understanding of Peer Review Organization criteria and standards, including Interqual and Millman Roberts
    • Must have understanding of Medicaid regulations and standards related to utilization review
    • Excellent written and oral communication skills
    • Ability to prioritize tasks and respond to multiple demands
    • Effective problem solving
    • Strong computer skills and knowledge of computer programs (MS Word, Excel and UR software)
    CPR required:
    • Only certifications issued by the American Heart Association or the American Red Cross will be accepted.

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    Job Snapshot

    Employee Type
    Part-Time

    Location
    Chicago, IL

    Job Type
    Health Care, Nurse

    Experience
    Not Specified

    Date Posted
    09/20/2022


    This job has expired.

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