Pediatric Utilization Review Jobs in Virginia (NOW HIRING)

Job Description:
Summary:
Patient Resource Management is a comprehensive, coordinated approach to planning high quality patient care for all patients from the neonate, infant, pediatric, adolescent, adult and geriatric population (s). RN - Patient Resource Managers function as the non-physician team leader and as such assume overall responsibility for coordinating services, programs, and personnel necessary to maximize patient outcomes and quality care, ensuring efficient movement of the patient through the continuum of care, and minimizing unnecessary resource utilization in a selected group of patients. To perform this function, the RN - Patient Resource Manager must have exceptional clinical assessment and intervention skills to oversee the care provided their assigned patient population. The RN - Patient Resource Manager must review the patient's status daily and identify issues requiring intervention. They must anticipate, plan and discuss patient needs with the patient and family, physician, members of the interdisciplinary team, and third-party payers.
As the non-physician team leader, the RN - Patient Resource Manager must ensure appropriateness and timeliness of medical interventions and ancillary services. They are to ensure a collaborative and team approach to patient care to minimize delays in care delivery and ensure positive outcomes. The RN - Patient Resource Manager oversees the collection of appropriate data that identifies opportunities for improvement in service delivery and assists in improving the efficiency and effectiveness of services when appropriate. This individual must work closely with physicians and intervene when barriers to care are encountered. In addition, this individual will oversee clinical documentation in assigned patient groups to ensure documentation is complete and accurately reflects patient's status and medical interventions completed.
The RN - Patient Resource Manager is responsible for ensuring ongoing communication and collaboration with payer sources, achieving appropriate pre-certification and ongoing concurrent certification such that Ballad Health is paid appropriately for services provided. As such, the individual must have an in-depth knowledge and ability to apply various payer's rules and regulations, admission, discharge and continued stay reimbursement criteria and both Interqual and Milliman Guidelines. The RN - Patient Resource Manager must ensure that patients are admitted appropriately, and that continued care is appropriate for their clinical needs in the appropriate place in the continuum. While the RN - Patient Resource Manager must monitor resource management and cost effectiveness of care for their assigned patient population; patient safety and achieving positive clinical outcomes will always be the ultimate guiding force in the Patient Resource Manager's position.
As part of this role, the RN - Patient Resource Manager must also oversee the discharge planning process - including plan development, implementation, education and acquisition of resources for a successful discharge. The RN - Patient Resource Manager oversees utilization of patient care protocols and clinical pathways and ensures appropriate patient and family education has occurred prior to discharge. This individual demonstrates competency in the care of Neonate, Infant, Child, Adolescent, Adult, Geriatric patients.
Requirements:
Associate's or Bachelor's degree from an accredited Nursing program. Varied clinical experience. Experience in Quality, Case Management, Utilization Review, or similar field is preferred.
Licenses and Certifications:
Valid and active RN licensure in appropriate state
BLS Required
Work Requirements:
Shift: Day
On Call: No
Weekends: Rotating
Travel Required: No Travel
Shift Details: 8a-630p
City/State: Abingdon, VA
The range for this position is $56,992.00-$82,222.40. Actual rate is dependent upon experience.
Location:
Johnston Memorial Hospital