• Job Description

  Req#: 2025-026974
  Newport News, Virginia

  This is not a remote position, this position is located on site at Riverside Regional Medical Center in the Emergency Department working 12 hour shifts.

  Full Time-Available Shift: 11am-11pm

  
  Overview
  Responsible for the judicious management of health system resources through advocacy for both the patient and the organization. Provides initial medical necessity reviews for all patients hospitalized within the organization in accordance with national guidelines and standards of excellence, in accordance with the UM Plan established by the organization, facility goals, and strategic plans.
  
  What you will do

  • Recognizes and demonstrates shared accountability, both at the patient and the team level. Contributes to decision-making and decision support as a member of the interdisciplinary team. Provides level of care determination to physicians (Emergency and Attending) based upon thorough medical record review and knowledge of federal and evidence-based guidelines, including CMS Conditions of Participation.
  • Aligns practice with organization's mission and vision. Advances the application of research and evidence-based practices through the expert use of MCG national guidelines when assigning levels of care to admitted patients. Communicates effectively and professionally regarding modality. Provides education regarding utilization management to patients, families, and other members of the care team as needed.
  • Maintains current knowledge of health care economics, trends, and reimbursement methodologies, and applies this knowledge to daily practice. Remains current via continuing education, MCG Interrater Reliability, and ACMA Compass modules.
  • Respects and incorporates patients' goals of care and treatment preferences while respecting available resources. Builds and maintains relationships that foster trust and confidence. Engages with physician leaders to provide education and promote optimal patient care. Routinely collaborates with members of the interdisciplinary team, physician advisors, and facility leadership.
  • Advocates on behalf of patients/families/caregivers for service access or creation and for protection of the patient's health, well-being, safety, and rights. Promotes and engages in culturally competent care. Partners with providers and payers to ensure the patient can access their full benefits. Balances resources with patient preferences. Advocates for the organization regarding compliance with the administration of required notices when medical necessity does not exist and ensures the patient/family is in complete understanding.
  • Manages cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Informs the interdisciplinary team of the economic impact of treatment options. Facilitates care delivery for the setting and duration that is appropriate to the clinical need. Applies knowledge of contractual arrangements and payment models to daily practice.
  • Embraces and incorporates innovation and technology to improve collaboration and patient outcomes. Ensures compliance with organizational policy and regulatory requirements to securely transmit patient information and protect their health information. Utilizes established processes for secondary review when warranted.

  
  Qualifications
  
  Education

  • Program Graduate, Professional Nursing (Required)
  • Bachelors Degree, Nursing (Preferred)

  
  Experience

  • 3-4 years Clinical nursing experience (Required)

  Skills and Abilities

  • Excellent verbal and written communication skills
  • Excellent interpersonal skills
  • Excellent organizational skills and attention to detail
  • Ability to act with integrity, professionalism, and confidentiality
  • Proficiency with computer systems required to perform job

  
  Licenses and Certifications

  • Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required)
  • Certified Case Manager (CCM) - Commission for Case Manager Certification (Preferred) or
  • Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred)

  Other Requirements

  • Weekend Shifts
  • Irregular Shifts

  To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.

• About the company

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