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Advocate Health Care is currently seeking candidates for a Quality Improvement- QI position.

This position is responsible for enhancing patient care and satisfaction through quality activity, monitoring and to coordinate and execute the specific tasks required for efficient and effective operation of the quality improvement program in accordance with department, contractual and regulatory agency standards.Qualifications: Good organizational and interpersonal skills.Computer skills, basic keyboard knowledge. Willingness to be flexible with work scheduleKnowledge of managed care or utilization review or hospital quality. BSN or 2-4 equivalent years experience in managed care.1-2 years experience in utilization management/QI activity. 3-5 years of clinical experienceCurrent RN license issued by the state of IllinoisCurrent CPR certificationAdvocate Health Care, based in Oak Brook, Illinois, is the largest fully integrated health care delivery system in metropolitan Chicago and the state of Illinois, and is recognized as one of the top health care systems in the country. Advocate is the second largest private sector employer in metropolitan Chicago with more than 25,000 associates and has the largest trauma network in the state of Illinois.

Who Cares? We Do!. . . for our patients, our communities, and each other Allina Hospitals & Clinics!Located in Minnesota and western Wisconsin, we are a not-for-profit system of hospitals, clinics and other health care services, united in caring for our patients with unparalleled talent, knowledge and technology; caring for our communities through collaborative efforts to promote stewardship, compassion and wellness; and caring for each other in an environment that puts patients first and helps passionate people excel. This is what makes Allina unique. Won´t you join us?Allina Commons is the Minneapolis-based headquarters of Allina Hospitals & Clinics, a not-for-profit health care organization serving patients and communities. Approximately 1,600 corporate and administrative service employees work at offices within Midtown Exchange, site of the historic Sears retail complex at Chicago Avenue and E. Lake Street. This community landmark, adjacent to the campus of Allina´s Abbott Northwestern Hospital, is the second largest building in Minnesota and includes offices, an internationally themed public market and residential units.Responsibilities:Assess inpatient and observation admission according to admission criteria for all different hospital disciplines (Mental Health, Substance Abuse, Acute Care, Rehab, Observation, etc.) Assess clinical data from medical records to assure appropriateness of patient´s admission. Ensure proper authorization requirements are met with each admission. Monitor continued stay, identify potential issues, and communicate the results and opportunities to nurses, physicians, finance, case managers, and payers. Provide consultation to medical and nursing staff, health information management, payers, patients, and patients on potential issues with reimbursement of hospitalization. Evaluate potential denials or payment issues and initiate communication with physician and / or clinician to assure proper documentation for selected admission status. Assure proper physician order is in the record for the correct patient status. If the order is incorrect, facilitate discussion with the appropriate physician. Refers case to a review physician when the treatment request does not meet necessarily per guidelines, when guidelines are not available, or per customer account instructions. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the attending provider.Qualifications:RN - BSN preferred. 3-5 years of acute care experience preferred. Understanding/ knowledge of Interqual and Milliman and Roberson Admission criteria, preferred. Knowledge of medicare, medicaid, and other third party payer admission requirement. Knowledge of managed care concepts including utilization management, prior authorizations, and denial and appeal process.Pay, Benefits & Work Schedule:***Temporary position*** 32 hours per week Day and Evening shifts Every other weekendWe have a place for you at Allina Hospitals & Clinics. If you are interested in becoming part of our award winning team of professionals, please apply online today at www.allina.com/jobs and reference job opening id 416930. Allina is proud to offer highly competitive salaries and comprehensive benefits that include a 401(k)/403(b), tuition reimbursement, day care reimbursement accounts, banking services and much, much more. Check online for other opportunities throughout Allina!

Specializing in you...serving San Diego´s inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles.

Specializing in you...serving San Diegos inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles. As the largest hospital district in Southern California, we are also one of the most diverse. From our state-of-the-art Cardiac Care and Rehabilitation Facilities and busy Trauma Center to Home Healthcare, we deliver a full spectrum of health services to meet the needs of every member in our community.We have an excellent opportunity for a Full-Time Defense Audit Denials RN who will be responsible for the clinical review of all charges on patient encounters in five primary areas of focus: 1) payer defense audits 2) pre-billing chart to charge reviews on high risk patient encounters for compliance and /or lost revenue 3) post billing chart to charge reviews as areas of risk are identified 4) clinical denials to mitigate the loss of revenue 5) refund requests to review for missing chargesResponsibilities include:Summarize reviews into clear and concise reports for management review.Reports to include recommendations for corrective action, which can include staff training and process improvement; creates and maintains database of reviews performed and reports trends to management at least monthly; serves as a resource to clinical areas to identify lost charge improvement opportunities.Possess analytical ability to design methods, collect and review data, formulate appropriate solutions and compile reports. This individual prioritizes work based on findings and risk; performs multiple tasks and modifies review approaches based on the organizations changing situations and needs, and follows through to achieve final resolution. Ability to effectively communicate, both written and verbal, with all levels of the organization. Work independently and as a cohesive team member seeking opportunities throughout PPH to improve effectiveness in charge capture and increased accuracy of clinical documentation. Responsible for coordinating and managing appeals for clinical denial of payment by medical record review with input from the physician advisor, attending physician, nurse case managers, and UR nurses. Serves as a liaison between patient financial services (PFS). Provides Case Management (CM)and Utilization Review (UR) for appeal-denial related issues. Generates formal letters of appeal to the insurance carrier. Responsible for collecting and maintaining data relating to appeals and outcomes.Explores opportunities for improvement in an effort to increase hospital reimbursement and decrease the rate of clinical denials.Maintains ongoing education and working knowledge of insurance regulations and claims audit. Maintains data spreadsheets with ability to prepare and present reports as requested. Maintains and utilizes excellent interpersonal, verbal and written skills effectively with ability to work independently to prioritize workload to meet appeal deadlines. Performs other duties as assigned. Follows PPH rules, policies, procedures, applicable laws, and standards.Carries out the mission, vision, values, and quality commitment of PPH.We promote a philosophy that encourages growth and satisfaction. We provide a work environment that is open and empowering, where you can experience a wide range of clinical, educational, and management opportunities. We also support a healthy balance between your personal and professional lives. We are located in an area that is enriched with a sense of belonging, where everyone pulls together in a common philosophy of life. Its an area that affords all who live here the luxury to pursue any interest or lifestyle they choose.RequirementsMinimum Education: As required by certification and/or licensurePreferred Education: Bachelors Degree in NursingMinimum Experience: 2 years hospital denials management, 4 years experience in an acute care facility and/or health care consulting; and Quality Assurance/Utilization ReviewPreferred Experience: 4 years hospital denials management, 5 years experience in an acute care facility and/or health care consulting; Quality Assurance/Utilization ReviewRequired License: Current CA RN License and Valid Drivers LicenseWe invite you to join us in our Mission to Heal, Comfort, and Promote Health in the Communities We Serve!