Mission Community Hospital is a 145 bed Acute Care facility with a 50 year history of serving the San Fernando Valley with a mission of compassionate care. Currently we seek a Part Time Utilization Review & Denial Management Nurse/Coordinator with details below. POSITION SUMMARY All employees are expected to perform their duties in alignment with the vision and values of the organization. The person doing this job is responsible for a variety of tasks that lead to a high level of customer satisfaction in the most cost-effective manner. Responsible for Utilization Review, Denial Management and other Case Management activities as assigned within the Hospital. MAJOR RESPONSIBILITIES 1. Improve the accuracy of medical record documentation by educating physicians and nurse practitioners to reflect severity of illness and the resources used to treat patients: Establish process for tracking physician documentation query activities and monitor process for compliance and effectiveness. Report query documentation improvement data to assigned committees. Independently performs daily concurrent chart reviews on all assigned patients to ensure documentation is comprehensive and accurately reflects severity of illness and intensity of service. Ensure physicians documentation is clear and comprehensive and includes: 1) principal diagnosis; 2) procedures; 3) complications; 4) co-morbidities (all relevant pre-existing conditions); 5) signs and symptoms when diagnoses are not established; 6) abnormal lab and diagnostic findings; 7) suspected conditions and what was done to evaluate them; and 8) discharge status and disposition. Work collaboratively with HIM staff to ensure all documentation queries are signed by physicians. Follows-up to ensure documentation queries are reviewed and signed by physicians prior to discharge. Notifies HIM coding staff timely with diagnoses updates. Develop new physician query documentation tools, as indicated. 2. Review Medi-Cal denials for appropriateness. Discuss findings with physicians and staff when denials are determined to be justified and provide timely education to help prevent unnecessary denials. 3. Discusses medical necessity/medical management issues with attending/responsible physicians and physician advisor, when indicated. 4. Works with the private insurance case managers, ensuring clinicals reflect patient acuity and proper patient discharge planning. 5. Refers cases not meeting criteria (including situations involving the timely provision of services) to Physician Advisor or Medical Director as appropriate. 6. Maintains working knowledge of regulations and provider contracts governing coverage of inpatient services, i.e., Medicare, Medi-Cal, California Children Services, Genetically and Handicapped People Program. UR & Denial Management Coordinator Revised 03/2009 2 7. Maintains objectivity and good interpersonal skills, which allow for effective interaction with a wide variety of people. 8. Participates in staff meetings, committee meetings, team conferences and other activities as assigned. 9. Maintains accurate and updated notes/records of physician documentation query and UR activities as required. 10. Identifies and refers situations requiring immediate intervention to Risk Management/QI Director or Medical Director as indicated. 11. Participates in the orientation of new employees or cross training of other case managers as needed. 12. Actively participates in UM, CM and denial management staff and physician education or hospital in-services. QUALIFICATIONS: Minimum of two (2) years direct patient care experience in an acute psychiatric setting. Med/Surg. experience desirable. Previous experience in Case Management, Utilization Management or Denial Management preferred. Must be able to demonstrate the knowledge and skills necessary to conduct through medical record audits and determine if severity of illness documentation is appropriate. Must be able to exercise independent discretion and judgment (utilizing approved criteria) in the performance of utilization and denial management functions. Minimum Education: Associate Degree in Nursing. Bachelor’s Degree in Nursing preferred. Specialized Training: Case Management, Utilization Management and/or Denial Management preferred. Licensure: Registered Nurse with current California License. Must have a valid Driver’s License. Software: Basic Microsoft computer skills required.