Job Description

Overview

FirstHealth of the Carolinas is a nationally recognized health care system located in central North Carolina. Comprised of four hospitals with more than 600 beds, the system also offers leading-edge heart care in the Reid Heart Center, the area's only dedicated heart and vascular center. As of March 2023, FirstHealth of the Carolinas officially opened its new comprehensive cancer center to patients. Our growing health system has more than 5,400 employees serving in more than 75 locations throughout a 15-county service area. In addition, the system provides home health and hospice services, emergency care, and medical transportation. FirstHealth of the Carolinas has over 50 primary care, specialty care, convenient care and dental clinics located throughout our service area.

We are committed to a culture of excellence in which everyone feels valued and connected, and where differences are both respected and supported. Our career opportunities allow our staff to practice in a team environment as a vital part of growing a widely respected health care system and medical community. We have been named Becker's Top 150 Places to Work in Healthcare for a third year in a row.

Great benefits package

Free FirstHealth fitness center membership

PSLF Qualifying Employer

Responsibilities

Utilization Review Nurse (RN) Job Summary

• Reviews each new patient record using criteria guidelines per policy for medical necessity and ensuring that patients are in the appropriate status/level of care. Includes initial review and continued stay review per guidelines and as requested by payor.
• Refers recipients of Medicare and Medicaid who do not meet criteria to Physician Advisor.
• If facilitated to Physician Advisor as the next step, follows through with their recommendation for Level of Care by obtaining order and providing Outpatient/Observation notices as required per policy.
• Performs continued stay reviews per policy and submits clinicals to payers per protocol by responding to requests for additional information within same business day.
• Reviews all denials, providing additional clinical as requested, arranges peer to peer as needed, updating Denials Management Specialist in process thereby assisting in facilitating correct billing and payment. Collaborates with: admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of appropriate level of care in the electronic medical record and for billing accuracy.
• Assists discharge planning staff in clinical decision-making and priority setting to ensure an optimal length of stay.
• Consistently courteous to visitors, patients, and fellow employees whether speaking directly or by telephone. Routinely anticipates the needs of others and seeks opportunities to be courteous.
• Serves as a liaison for the physician/nursing staff/ancillary departments to implement processing of the appropriate patient level of care through the healthcare delivery system.

Qualifications

Utilization Review Nurse (RN) Qualifications

• Bachelor's Degree in Nursing with a minimum of 3 years nursing experience in medical/surgical, critical care and/or hospice, home health or public health required
• OR Associate Degree in Nursing with a minimum of 4 years' experience in medical/surgical, critical care and/or hospice, home health or public health required.
• Master Degree in Nursing or related field preferred.
• Case Management (ACM or CCM), MCG certification preferred.

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