Job: Other Nursing Services
Primary Location: TN-Nashville-Monroe Carell Jr. Children's Hospital at Vanderbilt
Organization: Pediatric Utilization Mgmt 209355
Utilization Mgt Specialist- RN PEDs -VCH
Required: RN and BSN
Facilitates optimal reimbursement through accurate certification and complete chart documentation ensuring that the appropriate admission status is ordered. Conducts initial admission based on utilization review medical necessity criteria. Refers cases for secondary review when appropriate. Refers and consult with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.
- Facilitates optimal reimbursement through certification and denial processes.
- Facilitates throughput of patients admitted urgently or emergently through the emergency department.
- Participates as an active partner with multidisciplinary team members to ensure case is in the appropriate level of care setting.
- The responsibilities listed are a general overview of the position and additional duties may be assigned.
UTILIZATION REVIEW (INTERMEDIATE):- Demonstrates expertise of utilization review in practical applications of a difficult nature. Possesses sufficient knowledge, training, and experience to independently complete clinical review to obtain payor authorization. Demonstrates mastery in InterQual Level of Care Criteria and Milliam Care Guidelines. Able to train and educate by setting the example, giving technical instruction, providing leadership, and generally raising the level of performance of others while on the job.
MEDICAL TERMINOLOGY & DOCUMENTATION - (NOVICE):- Possesses sufficient fundamental proficiency to successfully demonstrate medical terminology and documentation in practical applications of moderate difficulty.
INTERDISCIPLINARY EDUCATION (NOVICE):- Seeks to provide education by collaborating with providers and other members of the health care team to ensure that the patient is placed in the appropriate level of care setting.
CLINICAL APPLICATIONS SYSTEMS (NOVICE):- Possesses fundamental proficiency in utilization review systems, clinical support systems and business support applications as needed
- Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
- Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
- Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
- Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.
SUPPORTING COLLEAGUES (P3):
- - Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
- - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
- - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.
DELIVERING EXCELLENT SERVICES (P3):
- - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
- - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
- - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.
ENSURING HIGH QUALITY (P3):
- - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
- - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
- - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.
MANAGING RESOURCES EFFECTIVELY (P3):
- - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
- - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
- - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.
FOSTERING INNOVATION (P3):
- - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
- - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
- - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.
Other : Bachelor's of Science in Nursing and 1 year relevant experience
Licensure, Certification, and/or Registration (LCR):
- Registered Nurse Required
Physical Requirements/Strengths needed & Physical Demands:
- Light Work category requiring exertion up to 20 lbs. of force occasionally and uses negligible amounts of force to move objects.
- Occasional: Standing: Remaining on one's feet without moving.
- Occasional: Walking: Moving about on foot.
- Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another
- Occasional: Lifting over 35 lbs: Raising and lowering objects from one level to another, includes upward pulling over 35 lbs, with help of coworkers or assistive device
- Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.
- Occasional: Push/Pull: Exerting force to move objects away from or toward.
- Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles
- Occasional: Balancing: Maintaining body equilibrium to prevent falling when walking, standing, crouching or maneuvering self, patient and equipment simultaneously while working in large and small spaces
- Occasional: Climbing: Ascending or descending stairs/ramps using feet and legs and/or hands and arms.
- Occasional: Kneeling:Bending legs at knees to come to rest on knee or knees.
- Occasional: Crouching/Squatting: Bending body downward and forward by bending legs and spine.Reaching above shoulders: Extending arms in any direction above shoulders.
- Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.
- Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.
- Occasional: Bimanual Dexterity: Requiring the use of both hands.
- Frequent: Sitting: Remaining in seated position
- Frequent: Reaching below shoulders: Extending arms in any direction below shoulders.
- Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.
- Continuous: Communication: Expressing or exchanging written/verbal/electronic information.
- Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information
- Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.
- Continuous: Smell: Ability to detect and identify odors.
- Occasional: Chemicals and Gasses: Medications, cleaning chemicals, oxygen, other medical gases used in work area.
- Occasional: Pathogens: Risk of exposure to bloodborne pathogens and other contagious illnesses.