RN INSURANCE SUPPORT / 8 HOURS / DAYS / BWH DEPT. OF CARE COORDINATION
Location: Boston Massachusetts
Description: Brigham and Women's Hospital (BWH) is at present looking to employ RN INSURANCE SUPPORT / 8 HOURS / DAYS / BWH DEPT. OF CARE COORDINATION right now, this vacancy will be placed in Massachusetts. More complete informations about this vacancy opportunity kindly read the description below. Responsibilities:
GENERAL OVERVIEW:
The Registered Nurse is a professional nurse registered in Massachusetts who is responsible and accountable for planning and providing patient care for assigned patients in accordance with Nursing Standards of Care as set forth in the Nursing Department’s Clinical Practice Manual.
The registered nurse demonstrates initiative, knowledge and clinical skills in caring for the
patient with complex needs. The Registered Nurse demonstrates the ability to effectively
manage patients by assuming full responsibility for the assessment, plan, implementation and
evaluation of patient care and is directly responsible to a designated nurse manager, or
supervisor.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
CLINICAL PRACTICE:
A. Organization of Patient Care:
1. Accountable for assessing, planning, implementing and evaluating a plan of care
for a specific patient assignment.
2. Sets priorities when organizing care for patients with varying acuity.
3. Maintain continuity through clear and concise (verbal and written) communication.
4. Demonstrates appropriate knowledge of growth and
development of the adult and geriatric patient. In areas, such as the NICU and Obstetrics
the principals of growth and development are applicable to the neonate.
B. Quality of Care:
1. Documents patient care in a manner that is clear, complete, concise and in compliance with
nursing documentation standards.
2. Develops a comprehensive plan of care based on data from an initial assessment of patient
and family, information from other members of the health care team, intra-agency referral
and previous medical records.
3. Develops a comprehensive educational plan for the patient and family, utilizing appropriate
resources and documents according to the department’s documentation standards.
4. Develops a comprehensive discharge plan utilizing appropriate resources and referrals
including community resources.
5. Evaluates the effectiveness of the plan of care, and documents progress in meeting
stated goals. Revises plan of care as needed to achieve desired outcomes.
6. Participates actively in the unit-based and organizational quality management and/or
quality improvement programs.
7. Provides a safe environment for patients, staff, family and visitors.
8. Administers medication safely according to established policies and procedures.
9. Performs nursing procedures safely and efficiently.
10. Uses equipment safely and efficiently.
11. Demonstrates awareness of potential/actual risks of infection and modes of transmission.
Utilizes universal precautions in nursing practice.
C. Coordination/Collaboration:
1. Interacts with patients, families, and colleagues in a professional manner.
2. Collaborates with other discipline(s).
3. Develops, utilizes and evaluates unit-specific standards of care.
4. Upholds the A.N.A. code of ethics and acts as a role model to other staff members.
5. Participates in determining and implementing goals and objectives for the unit.
6. Participates in determining goals and objectives in the periodic review and evaluation.
7. Serves on unit-based and organizational committees, and disseminates information to
peers.
D. Education:
1. Assumes responsibility for personal and professional growth through identification of own
learning needs.
2. Shares knowledge and experience with colleagues.
3. Participates in unit-based and organizational educational programs.
4. Seeks and accepts guidance for additional learning needs.
E. Research:
1. Utilizes nursing research findings in clinical practice.
2. Contributes to nursing and/or medical research endeavors by supporting investigators.
F. Budget:
1. Utilizes time and materials in an effective and economical manner.
2. Provides suggestions which support the delivery of cost effective health care.
3. Assesses patient's acuity accurately when making decisions regarding staffing,
transfers and assignments.
4. Demonstrates awareness of the need to manage within established budgetary
boundaries.
G. Personnel:
1. Participates in the orientation of new staff members, students and others as
appropriate.
2. Provides input into the clinical evaluation of other staff, as appropriate.
3. Assumes responsibility for the unit in the absence of leadership personnel.
4. Adheres to hospital and nursing policies and aids in their interpretation to others.
5. Recommends change in policies and procedures through appropriate channels.
6. Participates in the cooperative effort and peer support required for the smooth
running of the unit, e.g., flexibility in relation to patient assignments, shift
assignment, or work schedule.
Requirements:
QUALIFICATIONS:
A. Education:
Graduate of an approved school of nursing with current registration in
Massachusetts. For newly licensed nurses a Bachelor of Science Degree inNursing is required.
B. Experience:
Prior experience not required unless specified for certain specialty areas.
C. Other:
Membership in professional organizations is recommended and certification in
a specialty area is encouraged.
SKILLS AND ABILITIES REQUIRED:
The RN must show evidence of the basic analytic thinking necessary to care for a group of
patients. Must demonstrate observational skills and the ability to set priorities. Must be able to
function under stress with good interpersonal and communication skills. Must demonstrate
effective skills in applying hospital standards in area of service, team work, communication,
respect for others, and time/priority management.
- Required to Work Weekends Per Contract.
Works in a variety of patient care environments where there may be exposure to communicable
diseases and hazardous materials such as chemotherapeutic agents, radioisotopes, and radiation. Work entails walking and lifting
Shift:
Day Shift
EEO Statement:
An EEO, AA, VEVRAA Employer
Additional Information
GENERAL SUMMARY/ OVERVIEW STATEMENT:
The Insurance Support Nurse participates in the timely management of denials that are received in the Care Coordination Department. Through sound knowledge of utilization management the nurse is able to assess a patient’s level of care after review of the medical record. The nurse is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and finale case closure. The nurse works closely with admitting and finance staff, to process denied claims.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Utilization Management
Collaborates with appropriate individuals, departments and payers to insure appropriateness of admission, continued days of stay and reimbursement.
1- Utilizing industry accepted utilization and or medical management criteria and can apply criteria to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization.
2- Demonstrates working knowledge about different industry criteria sets like MCAP, AEP, Millerman and Roberson, and Interqual.
3- Demonstrates in depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
4- Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
5- Assists with the preparations of denial notices given to patients.
6- Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare.
Denial Management
Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided.
1- Reviews denial letters and sends letters to other departments if appropriate.
2- Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
3- Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies.
4- Documents denials in the BWH/Partner’s Denial Database.
5- Follows up with insurance companies on claims status for clinical denials.
Team Work
Assists with variety of functions and responsibilities of care coordination department to ensure that all state and federal mandates are followed. Participates in the ongoing evaluation of practice patterns and systems, support efforts to improve quality, cost and satisfaction outcomes.
1- Expert on observation status and reviews observation patients as assigned.
2- Assists in the completion of utilization reviews to insurers and intermediaries.
3- Anticipates and troubleshoots claim and reimbursement issues.
4- Assists in the review of Medicare reports as assigned.
5- Participates in BWH and Partner’s Finance projects.
6- Active Member of the ATO/Denial Committee and UMC Committee.
7-Other duties as assigned
QUALIFICATIONS:
RN required, MA license, BSN preferred.
Knowledge and skills to differentiate levels of care required.
Five years of previous acute care experience in variety of clinical specialties strongly preferred.
Two or more year’s experience with hospital utilization review and medical criteria sets preferred.
Certification in case management preferred.
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
Previous experience in a hospital or health care setting, strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and internal and external customers; strong organizational skills and ability to set priorities: ability to compile data from concurrent and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communication skills, computer skills.
WORKING CONDITIONS:
Works in a busy and t times stressful hospital/office environment. Must be able to work well and independently in a multidisciplinary group. Must be flexible. Travel required outside hospital/offices.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Brigham and Women's Hospital (BWH).
If you interested on this vacancy just click on the Apply button, you will be redirected to the official website
This vacancy starts available on: Thu, 12 Jul 2012 23:14:06 GMT
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