Registered Nurse - RN
Mason, OH 45040
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SUMMARY: Responsible to investigate and process grievances and appeals requests from members and providers.
MAJOR JOB DUTIES AND RESPONSIBILITIES: Conducts investigations and reviews of member and provider grievances and appeals. Reviews prospective, concurrent or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes essential medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory time frames. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Generates appropriate written correspondence to providers, members, and regulatory entities.
SKILLS: Requires broad and deep knowledge of medical policy, emerging technology and analysis of emerging evidence. Requires oral and written communication skills, problem-solving skills, PC skills, and research and analytical skills.
EDUCATION/EXPERIENCE: Requires Associate''s Degree in Nursing and 2-3 years experience in a managed care healthcare setting, or any combination of education and experience, which would provide an equivalent background. Requires current unrestricted RN license in applicable state(s). BSN preferred.
The Registered Nurse, as a professional practitioner employed by Maxim Healthcare Services, Inc., assumes responsibility and accountability for the application of the nursing process and the delivery of patient care. The nurse demonstrates ability to make clinical judgments in an effective and efficient manner with supervision. The nurse demonstrates critical thinking and performance ability in the coordination of patient care. Consistently performs according to nursing standards and is accountable in managing patient care and assisting others in the management of patient care.
Essential Duties and Responsibilities:
. Utilizes the nursing process to assess, plan, implement and evaluate patient care.
. Performs focused interview to identify specific patients needs.
. Assess signs and symptoms indicating physiologic and psychosocial changes in the patient's condition.
. Collects, analyzes, and interprets data and information from health care members and documents actual and/or potential nursing diagnoses.
. Documents the patient's plan of care using identified nursing diagnoses, expected patient outcomes, and selected nursing interventions.
. Identifies and prioritizes actions based upon patient care requirements.
. Monitors consistency between patient plan of care and actions of medical staff.
. Performs interventions according to identified priorities, plan of care, and the hospital policies and patient care outcome standard.
. Provides a safe, comfortable and therapeutic patient environment.
. Initiates and evaluates patient and/or family education.
. Revises the plan of care according to evaluation, changes in medical plan of care, and effective/ineffective nursing interventions.
. Documents patient's response to nursing and other interventions.
. Uses clinical judgment in evaluation activities to meet patient care needs of an assigned unit/floor including establishing priorities.
. Monitors the safety and effectiveness of the environment and equipment.
. Participates in activities to facilitate good interpersonal communications with the chosen facility.
. Supports professional practice by observing the following: Uses knowledge and practices in accordance with 1) the Nurse Practice Act; 2) Standards of Nursing Practice; 3) Standards of Patient Care; 4)JCAHO, state and local laws; 5) Patient's Bill of Rights; and 6) Maxim Healthcare, nursing and client hospital policies.
. Other duties as assigned
. Current Registered Nurse License for the state in which the nurse practices.
. Full command, verbal and written, of the English language.
. Current Health Certificate (per facility contract or state regulation).
. Current PPD or Chest X-Ray.
. One year prior professional nursing experience preferred.
. Current BLS card.
. Successful completion of screening tests for the clinical specialty area(s) in which the RN practices with a score of 80% or greater
. Maxim background screening
Physical/Work Environment Requirements:
. May work at off-site facility/ client site
. May be exposed to blood-borne pathogens, chemotherapeutic and toxic chemicals
Maxim employees are our greatest asset. We offer the following benefits:
-Medical, Dental, Vision, and Life Insurance
-Free Continuing Education (CE) Program
-Positive Work Environment and Friendly Staff Bonuses
-Travel Benefits (as applicable)
-24 hour on- call service
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Compensation and Benefits
$0.00 - $0.00 / hour