The position is located in the Division of Quality Management, at the Crownpoint Service Unit, Crownpoint, NM. The purpose of the position is to plan, organize, direct, implement, and evaluate the functions and requirements of the utilization review. Provides support to management delivering technical consultation and advice; analyzing, and interpreting data; monitoring, interpreting, updating, and implementing methodologies for the expedition of revenue collections.

Duties

Conducts utilization review functions and requirements: implements an on-going process for assessing and monitoring patient's charts and health status to determine appropriateness and completeness of medical documentation, length of stay, intensity of services, and allocation and utilization of resources for patient care. Consults with health insurance agencies to determine the accuracy of medical documentation on a patient's chart prior to billing for reimbursement. Reviews medical documentation and corrects such deficiencies to meet established criteria for severity of illness and intensity of service. Assesses the patient's physical and mental status for the purpose of making specific recommendations to the physician for alleviating patient problems and addressing health related needs. Participates in the Service Unit Utilization Review program. Leads scheduled Utilization Review Committee meetings. Applies professional nursing knowledge and abilities to audit inpatient charts for Diagnosis Related Groups (DRG) determination, length of stay, appropriateness of admission, and reports results to the Utilization Review Committee. Analyzes and projects fiscal year third party billing/collection based on inpatient per diem rate, outpatient visit rate, DRG case mix average for inpatient and outpatient, workloads, and available Medicare, Medicaid, and Private Insurance population data. Utilizes inpatient software, that provides guidelines for patient care to formulate judgment and understand why there is often a need for extended inpatient care and at other times to prevent unnecessary extended patient hospitalization. Collaborates with the respective practitioner for a denial on inadequate or incorrect medical documentation to ensure the appeal letter has been submitted to the State Quality Improvement Organization for case consideration. Routine duties shall include providing nursing care services to individuals eligible for services provided by the IHS in homes, schools, clinics, job sites, and other community locations within the assigned service unit.

Requirements

Qualifications

To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; social). You will receive credit for all qualifying experience, including volunteer and part time experience. You must clearly identify the duties and responsibilities in each position held and the total number of hours per week. BASIC REQUIREMENT(S): Education: A graduate or higher level degree, bachelor's degree, associate degree, or diploma from an accredited professional nursing educational program is required. This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained. Degree from Foreign Nursing School: Official certification from the Commission on Graduates of Foreign Nursing Schools is required for individuals who graduated from foreign nursing schools. Licensure: For all grade levels and positions, applicants must have passed the National Council Licensure Examination. In addition, they must possess a current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. In addition to the Basic Requirements, you must also meet the Minimum Qualifications stated below. MINIMUM QUALIFICATIONS: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Examples Include: Promotes the coordination, collaboration and continuity of care from admission to discharge, assesses the level of patient care needs, addresses the appropriateness of length of stay by ensuring patients meet medical necessity, provides education to clinical staff regarding third party payor requirements and medical liabilities; addresses denials from payors and pre-authorizations; monitors all admissions to meet regulatory requirements, including the coordination and collaboration with coding staff to meet internal control process; conducts and collaborates with inpatient care team related to discharge and case management. Time In Grade Federal employees in the competitive service are also subject to the Time-In-Grade Requirements: Merit Promotion (status) candidates must have completed one year of service at the next lower grade level. Time-In-Grade provisions do not apply under the Excepted Service Examining Plan (ESEP). You must meet all qualification requirements within 30 days of the closing date of the announcement.

Education

This position has an education requirement. You are strongly encouraged to submit a copy of your transcripts or a list of your courses including titles, credit hours completed, and grades. Unofficial transcripts will be accepted in the application package. Official transcripts will be required from all selectees prior to receiving an official offer.

Only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education may be credited. Applicants can verify accreditation at the following website: https://www.ed.gov/accreditation.

If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Crownpoint Healthcare Facility PO Box 358 Crownpoint, NM 87313 US
• Name: Navajo Area IHS Human Resources
• Email: [email protected]