Pre authorization nurse reviewer. Utilization review in patient, out patient, and diagnostic requests. Review for level of care per medical policy and mcg criteria.

Leads multi-disciplinary team meetings regarding the planning and implementation of patient care, facilitiates communication, and problem solving related to discharge planning.Maintains required records, reports, and statistics for Administration.Ensure compliance with established Hospital and departmental policies and procedures.Acts as liaison with physicians, Administration, and ancillary service personnel to analyze case management needs, identify problems, and evaluate overall department performance.Responds to insurance denials by analyzing and presenting information to justify care provided by the Hospital and recoup reimbursement.Evaluates case management utilization review and discharge planning trends and makes recommendations for improvement to the Senior Administrator.Leads the case management department and supports the educational needs of the department.Serves as a role model and mentor to case management and unit staff to demonstrate effective and customer service focused discharge planning / care coordination skills and strategies.Collaborates with the multi-disciplinary team to facilitate care through the continuum.

Oversee the daily operation for medical review on workers compensation and disability cases.Responsible for the quality of cases, assuring that all cases have concise and accurate information Acts as a liaison between physicians and medical review nurses assuring smooth transition of cases between departments.

Responsible for the performance improvement initiatives of the facility and assisted with the planning implementation and evaluation of all PI projects.Reorganized and restructured the quality department to adhere to state and federal regulations. Responsible for the development of the quality improvement plan, risk management plan, patient safety plan and utilization review plans. Reviewed and revised all departmental plans and scope of services on an annual basis. Responsible for the collection and the analyzing of quality improvement data hospital wide.Analyzed and collected data that related to patient safety issues such as fall risk, restraint use, medication errors.Developed the new fall risk program for the facility Provided monthly statistical reports regarding quality, utilization review, patient safety and risk management to quality council, medical executive committee and to the board of directors. . Assisted the medical staff in the design of reviewing and reporting procedures that will serve the purpose of quality assurance and cost containment provided Medical staff with monthly statistical reports in regards to quality initiatives, patient safety and risk management issues, and utilization review reports all in accordance with the condition of participation. . Served as the Chairperson on the Quality Council, Utilization review and Patient safety CommitteesOversaw the Peer review process for both medical and surgical.. Oversaw the case management department. Responsible for the daily operations of the utilization department and social services department. Analyzed data based on utilization trends of the facility knowledge of CMS and PA state regulations, Knowledge in writing plan of corrections regarding CMS condition of participation

Provide telephonic prospective, concurrent and/or retrospective review of requests for clinical services. Make coverage determinations for setting, duration and treatments/services requested by participants or attending physician. Review case management referrals for clinical appropriateness. Evaluate requests for procedures and services by evaluating diagnoses, clinical record and patient history against established medical criteria, benefit plans and coverage policies.Work with providers and participants to identify contracted facilities and practitioners for provision of services. Review appropriate setting and duration of admission, treatment and discounts for services with attending physician

Supervises the performance and daily operations of assigned team members. Provides regular feedback to staff on performance and developmental opportunities. Supports and ensures staff involvement on critical training activities. Supports all office and divisional diversity initiatives.Communicates individual and team expectations to achieve desired departmental and corporate results. Supports and represents team on project initiatives. Inform team members on the status of key initiatives. (Divisional and departmental). Communicates customer feedback relevant to preferences, requirements, and industry trends to office and appropriate business partners. Fosters and environment of dependability and teamwork. Participate in special projects with focus on quality improvement and improved customer service. Interface with sales/client service managers as appropriate to meet customer needs. Participate in customer visits as requested. Daily contact with customers to resolve service delivery

Provide telephonic prospective, concurrent and/or retrospective review of requests for clinical services. Make coverage determinations for setting, duration and treatments/services requested by participants or attending physician. Review case management referrals for clinical appropriateness. Acts as a preceptor and resource to other team members.Evaluate requests for procedures and services by evaluating diagnoses, clinical records, and patient history against established medical criteria, benefit plans and coverage policies.Work with providers and participants to identify contracted facilities and practitioners for provision of services. Review appropriate setting and duration of admission, treatment and discounts for services with attending physician.

patient care oncology, IV team

responsible for patient care on Med/surg and pediatric patients