We are North Shore Medical Center. Our primary function is to offer continuous nursing, medical, and other health and social services on a 24-hour basis, under physician directed care and RN supervision.

We service a multitude of patients and their families across our vast network, while remaining committed to the professional development of our staff, the functional improvement of our patients, and the cultivation of strong partnerships within our communities.

What We Offer

Essential/stable and growing company with many opportunities for training and advancement within the medical field that all employees and team members (including Full-Time and Part-Time) can benefit from.
Hourly pay is negotiable based on experience. We offer competitive market pay and opportunities for bonus depending on great work performance (bonuses only apply for Full Time).
Comprehensive Employee Benefits: Full-Time employees are eligible for various plans for medical, dental, and vision insurance.

Job Duties/Responsibilities

The Utilization Review Specialist is responsible for assisting in the facilitation of critical criteria reviews on patient for behavioral medicine admissions and continued stays, completion of certifications/interfaces with managed care organizations, external reviewers and other payer's.

Job Summary

The Utilization Review Case Management specialist

Principal Duties And Responsibilities

Maintains recognition and acceptance of accountability and responsibility for duties and functions within the scope of the practice of the RN; collaboration with other team members towards problem resolution; precise and appropriate verbal and written communication; and behaviors consistent with the role of the professional nurse.
Reviews patient's medical records to collect data pertaining to diagnoses and major procedures performed, evaluates appropriateness of admission, observation and length of stay, and completes required forms.
Reviews patient's medical records for particular aspects of care (as directed) and/or problems which adversely affect patient care.
Performs concurrent reviews of admissions to determine medical necessity for admission, observation and continued stays. Refers those that do not meet criteria to the Physician Advisor and/or Department Chairman.
Performs concurrent reviews for the appropriateness of resource consumption and refers any over or under utilization to the Physician Advisor.
Reviews specific incidents and utilization problems with Physician Advisor such as extended hospital stays, complications with care, and patients waiting for placement.
Conducts ongoing utilization review for compliance with approved third-party treatment plan and ensures necessary interventions. Communicates with payors regarding clinical updates and the need for continued hospitalization.
Follows through on the assessment of the RN Case Manager for discharge planning and educational needs in the absence of that case manager; plans the patient's care and ensures that patient family teaching is complete.
Consistently supports the hospital's Spirit of Serving Standards, in line with the Mission, Vision and values of St. Joseph Medical Center.
Supportive of the compliance program set forth by SJMC and demonstrated by:
Upholds the Code of Ethics and Corporate Compliance.
Adheres to and helps to enforce all compliance policies relevant to his/her area.
Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
Sets an example to all staff in their daily activities.

Work Experience

MINIMUM KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

Two years experience as a Clinical Nurse, proficient in clinical and technical skills in nursing specialty; leadership and teaching skills in order to gain a full understanding of case management practices and procedures.

License/Registration/Certification

Current RN licensure issued by the Board of Nurse Examiners issued by the State of Florida.

Education & Training

Bachelors Degree in Nursing from an accredited School of Nursing.

Skills

Technical, critical thinking, and interpersonal skills relevant to clinical area in order to effectively communicate with patients and physicians.
Knowledge of criteria used to assess medical necessity and appropriateness of hospitalization and continued care.
Ability to speak clearly enabling patients and others easy comprehension.
Ability to write and print legibly.
Demonstration of customer focused skills.

North Shore Medical Center

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