Registered Nurse/Utilization Review

APN Consulting Inc

Whittier, CA

JOB DETAILS
SKILLS
Acute Care, Billing, COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985), Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT), Discharge Plans, Durable Medical Equipment, Emergency Medicine, HIPAA (Health Insurance Portability and Accountability Act), Healthcare Reimbursement, Hospital, Licensed Practical Nurse/Licensed Vocational Nurse, Needs Assessment, Outpatient Care, PHP Scripting Language (PHP Hypertext Preprocessor), Patient Care, Patient Care Authorizations, Quality of Care, Registered Nurse (RN), Safety Codes, Safety/Work Safety, Utilization Management
LOCATION
Whittier, CA
POSTED
30+ days ago


1st TIME OK/ 2 YR EXP required for Utilization Review RN
every other weekend required or more depending on unit needs
no call or floating required
MUST HAVE experience with Milliman Care Guidelines and Acute Hospital Experience!!

The Emergency Prospective Review (EPR) Nurse RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all PIH and non-PIH facilities (for PHP members) after stabilizing care has been initiated for medical necessity and appropriateness. Also, the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies, Health and Safety Codes, and applicable laws (COBRA/EMTALA). The EPR-RN performs, and supervises the EPRN-LVN, in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient, Observation, or Outpatient).

Certs:
CA RN license

Skills:
Acute Hospital
Emergency Department
ICU
Admission Criteria
Benefits Eligibility
Care coordination
Concurrent Review
Data Abstraction
Determine Medical Necessity per Evidence-Based Guidelines
Discharge Planning
Needs Assessment/ Order DME
Pre-Cert Review
Prior Authorizations
Utilize Milliman Guidelines
CMS: Centers for Medicare and Medicaid Services
CPT (Current Procedural Terminology) coding and billing
DRG (Diagnosis Related Groups)
HIPAA guidelines (Health Insurance Portability and Accountability Act)
ICD 10 Coding
OSHA
The Joint Commission/ Core Measure/National Safety Goals
Hard Stop hospital experience
Excel

prefer business casual

RTO MUST BE SUBMITTED UP FRONT!Facility Name: PIH Health Whittier Hospital

Unit: ***

Shift:Mid 3x12-Hour (14:00 - 02:30)

Overtime Multiplier: 48 total hours in 1 week : 1.5%

Double Time Multiplier: 12 total hours in a day : 2%

Charge Nurse: ***

On Call: ***

Call Back: 1.5%

Holiday: 1.5%

Observed Holidays: Thanksgiving: Falls Within: 7:00 PM day before - 7:00 AM day after
Christmas: Falls Within: 7:00 PM day before - 7:00 AM day after
New Year's Day: Falls Within: 7:00 PM day before - 7:00 AM day after
Independence Day: Falls Within: 7:00 PM day before - 7:00 AM day after
Memorial Day: Falls Within: 7:00 PM day before - 7:00 AM day after
Labor Day: Falls Within: 7:00 PM day before - 7:00 AM day after

Holiday Comments: None

About the Company

A

APN Consulting Inc