This position is located with the Division of Quality Management at the Gallup Indian Medical Center in Gallup, NM. The purpose is to serve as the Nurse (Utilization Review) responsible for planning, organizing, implementing, & evaluating the functions & requirements of the utilization review. Technical consultation & advice; compiling, analyzing, & interpreting data; monitoring & interpreting methodologies for the expedition of revenue collections and comply with Federal and State agencies.

Duties

09/03/2024:This position is being re-announced to solicit additional candidates. Applicants who previously applied to this announcement need not re-apply unless submitting updated information and/or missing forms. This position is being announced concurrently under Excepted Service Examining Plan (ESEP)/Merit Promotion (MP) procedures. Please review vacancy announcement number IHS-24-GA-12447539-ESEP/MP; for eligibility requirements. NOTE: Applicants must apply separately for each announcement in order to be considered under ESEP/MP. Process for assessing and monitoring patient 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. Provide concurrent or retro review to third party payers as needed for certification of admission days as needed. Communicate with providers and nursing staff to ensure accurate clinical documentation is present in the electronic health records. Review denials for appeal, when received from Case Management. Collaborate with Business Office and Billing staff to track and review ensuring prior authorization has been completed on admission for third party eligible cases. Works with the Health System Administrator and Clinical Director to resolve complex medical documentation problems. Utilizes Registered Nurse Training and expertise to prevent denials by instructing and training the practitioners regarding complete and appropriate medical documentation for the patient's status and level of care, and that the documentation meets applicable guidelines, standards, policies, procedures. Assures that the Utilization Review program meets the Joint Commission and third party payer's guidelines and regulatory requirements. Analyzes and projects fiscal year third party billing/collection based on inpatient per diem rate, outpatient visit rate, Diagnosis Related Groups (DRG) case mix average for inpatient and outpatient, workloads, and available Medicare, Medicaid, and Private insurance population data.

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: GS-12: 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: experience that promotes the coordination, collaboration and continuity of care form admission to discharge, assess the level of care needed, appropriateness and length of stay; provides education regarding third party billing reimbursement requirements and liabilities; monitors admissions to meet accreditation requirements; conducts final review and coordinate of discharge/case management plans and familiarity with third-party resources eligibility criteria; including the patient referred care regulations. Provides consultation and guidance to health care teams on policies and procedures related to performance improvement. Collaborates with management, medical and administrative staff, and supervisors to initiate corrective actions. 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 https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Gallup Service Unit 516 E Nizhoni Blvd P O Box 1337 Gallup, NM 87301 US
• Name: Navajo Area IHS Human Resources
• Email: [email protected]