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Review evaluation with the care team, patient, family members, physician, and case manager as needed. + Responsible for evaluating utilization of patient services and patient progress.
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Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
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Provide physician review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays, and referral services. This role is part of physician leadership and involves working collaboratively with Utilization Management, Health Information Management, Revenue Cycle, Patient Financial Services, Patient Access, Managed Care, and Medical Leadership to provide updates, statistical trending, and changes to denial prevention measures with managed care payor agreements.
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Acts as a liaison with the Registration, Finance Department, Business Office, Physician groups, and all internal/external sources regarding authorizations, denials, and inquiries relative to utilization review.
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Serves as a liaison to patient, family, admitting, primary care physician, health care team, and hospital departments. Conducts chart review for appropriateness of admission and continued length of stay; Facilitates throughput.
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Provider agrees to cooperate with, participate in, and comply with, the quality assurance, risk management and peer review programs, grievance procedures and utilization control mechanisms implemented by the Medical Group and its Affiliates.
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Participate in leadership team by actively contributing in decision making, grievance follow up, building and company-wide initiatives and attending leadership team meetings such as stand up, Managing Acute Care Conditions (MACC), Nutrition at Risk (NAR), Utilization Review (UR), Quality Assurance Performance Improvement (QAPI) and other meetings as required.
$40 an hourExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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To provide quality, comprehensive nursing care in the Patient's home as prescribed by the physician in the plan of care. Our organization offers in-home services for adults with distinctive healthcare requirements.
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Helps develop, implement and review adherence to a quality improvement program that assesses the following items: continuous quality improvement (clinical and service indicators), utilization management, standard practice guidelines, peer review, incident reporting, provider satisfaction, patient satisfaction, patient grievances, policy and procedures, nurse practitioner / physician assistant protocols, credentialing, internal audits, and patient education.
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The Coordinator will compile and process all E-TARs according to guidelines, log all requested TARs in Medical TAR log (Lotus), notify physician of Medical denials, log in all TARs in CPSI, process all deferred TARs, communicate with medical nurse reviewer accordingly, copy medical records for TAR review and fax all requested TARs for new admissions, concurrent and discharge in a timely manner.
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Concurrent and retrospective clinical review of medical records to evaluate the appropriate utilization of services, facilitate optimal physician documentation and assignment of optimal DRG, coding assignment to reflect case mix index.
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This is a work from home position in Texas You must live in Texas for this role Position is 100% CM, Mon-Fri JOB REQUIREMENTS: Registered Nurse (RN) with current, valid, unrestricted license in state of operations 2 years clinical practice experience of direct clinical care to the customer 1 year experience in Condition Management or Case Management in a health insurance, managed care, physician office or hospital setting.
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Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum.
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Required Experience: Five years of acute care nursing including medicine/surgery, ICU, telemetry or Five years of Case Management experience in an acute setting or utilization review at a medical group or health plan.
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The LVN case transition coordinator performs utilization review by using criteria that demonstrate medical necessity to achieve reimbursement for services and ensuring appropriate utilization of hospital resources.
$33 an hourFull-timeExpandApply NowActive JobUpdated 2 days ago
utilization review physician jobs
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