Department:OH110_62500_000 Social Services Mcsa
Expected Weekly Hours:40
Position Purpose:At Mount Carmel, we’re committed to making a meaningful difference in the lives of our patients and communities. Our colleagues – people like you – share our passion for always going above and beyond to provide the highest standards of care.
Job Description Details:
Our professional nurses are truly the heart and soul of Mount Carmel. It is their resilience, humility and determination that drive positive patient outcomes. To support you, Mount Carmel provides continuous opportunities for personal balance, professional opportunity and clinical growth. Our culture of shared governance and collaboration creates an environment that puts the focus on what’s truly important – our patients and the communities we serve.
Utilization Management Specialist will provide education and acts as a resource to the UR Case Management staff for selection of the correct criteria set to determine the appropriate Level of Care (LOC) for either an admitted patient and/or for those patients who do not meet inpatient LOC criteria but their care is required for observation as an outpatient until a determination of admission or discharge can be made. The UM Specialist serves as the point of contact for their respective MCHS hospital for all RAC activity and UR functions.
- Participates in new associate orientation and training. Maintains RAC database and provides monthly RAC and denial updates to the department. manager, finance department and organizational integrity. Makes recommendations with the support of the department manager and the physician advisor whether to appeal or close RAC denial cases.
- Collaborates with revenue integrity, compliance, billing and coding to ensure that cases are coded and billed appropriately in accordance with federal rules and regulations.
- Works in collaboration with the secondary level review and physician advisors on cases to ensure correct level of care assignments. Monitors high dollar observation cases daily and follows up on observation cases daily with the UR case manager
- Graduate from school of nursing with current license to practice in the State of Ohio; baccalaureate required.
- Licensure / Certification: Nursing License through the State of Ohio
- Minimum of five years' experience in Utilization Review and proven experience in effectively monitoring associate performance and coaching to improve productivity and achieve business results.
Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.
Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, or physical ability.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.