Summary
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
Conditions of Employment
Selectee may be subject to a probationary period
U.S. Citizenship is required
Selective Service Registration is required for males born after 12/31/1959
This is a designated position covered by Public Law 101-630, requiring contact or control over Indian children. Due to this requirement, the agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes.
Confidential Financial Disclosure Form required.
Measles and Rubella immunization required for selectees born after 1957 and seasonal influenza immunization is required for all staff working in Indian Health Service health care facilities.
COVID-19 vaccination is required for all selectees prior to entrance on duty.
The selected individual is required to obtain and maintain any licensure requirements. If licensure are not obtained or maintained during employment, the employee will be subject to adverse actions, up to and including removal from Federal service.
Successfully pass the E-Verify employment verification check. To learn more about E-Verify, including your rights and responsibilities, visit .
You will need to set up direct deposit so we can pay you.
Background Investigation: If you are selected for this vacancy, you must undergo a pre-employment fingerprint check and background investigation. Fingerprint results and background investigation documentation must be cleared prior to hire. After you begin your employment, your continued employment is contingent upon the outcome of a complete background investigation as determined by the sensitivity level of your position. The investigation must find that you are suitable for Federal employment in your position. If you are found not suitable, you will be terminated after you begin work. If you make a false statement in any part of your application, you may not be hired; you may be fired after you begin work; or subject to possible criminal charges. You may be subject to a credit check as a part of the background investigation process.
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 , , , or an accrediting body recognized by the at the time the degree was obtained.
Degree from Foreign Nursing School: Official certification from the is required for individuals who graduated from foreign nursing schools.
Licensure: For all grade levels and positions, applicants must have passed the . 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.
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
Additional selections may be made for similar positions across the Department of Health and Human Services (HHS) within the local commuting area(s) of the location identified in this announcement. By applying, you agree to have your application shared with interested selecting official(s) at HHS. Clearance of CTAP/ICTAP will be applied for similar positions across HHS.
This position will be filled through the Office of Personnel Management's Direct Hire Authority. Category rating and Veterans' Preference will not be considered in evaluating applicants. For more information on Direct Hire Authority, please see . Your application (resume and supporting documentation) will be evaluated to determine if you meet the minimum qualifications required as listed on the announcement under qualification requirements. To be considered well qualified for the purposes of the Career Transition Assistance Program (CTAP) and the Interagency Career Transition Assistance Program (ICTAP), you must substantively exceed the basic qualifications and meet all eligibility, physical, medical, suitability, and any other requirements.
You will be further evaluated based on the information provided in your resume (your resume must state specific duties that relate to this position) and your responses to the assessment questions to determine your competency in the following
- Education and Training
- Planning and Evaluating
- Quality Assurance
- Technical Competence
- Technology Application
Required Documents
Resume: You are highly encouraged to use USAJOBS Resume Builder to ensure all required information is included in your Resume. If you use your own resume, curriculum vitae, or any other written form you choose then you must describe your job-related qualifications that includes beginning and ending dates for paid and non-paid work experience, hours worked per week, month and year of employment for each job title listed, annual salary, and description of job duties. Include name and address of employer; supervisor name and telephone number.
Required as applicable for the purposes of specific eligibility and appointment claim(s), and position requirements:
Indian Preference Applicants: If claiming Indian preference, applicants must provide a completed copy of the Form BIA-4432, "Verification of Indian Preference for Employment in the BIA and IHS Only." Indian preference will not be given unless a properly signed and dated form is submitted with your application, including any verification by an authorized Tribal Representative or BIA Official of tribal enrollment records. For detailed instructions, see form BIA-4432. Refer to BIA-4432 link: . When an Indian Preference candidate possesses Veterans preference the rules regarding Veterans preference apply under ESEP and the applicant must provide documentation in order to receive preference.
Career Transition Assistance Program (CTAP)/Interagency Career Transition Assistance Program (ICTAP): If you are claiming CTAP/ICTAP, follow the instructions below: .
Transcripts: You are encouraged to submit copies of transcripts (official or unofficial) although not required at the time of application. You must list your courses including titles, credit hours completed, and grades. Official transcripts will be required after tentative selection and prior to issuing an official job offer.
Licensure, Certifications: Applicants should list their license/certifications on their resume, along with the expiration date, if applicable. Certification of licensure/certification will be required after tentative selection and prior to issuing an official job offer.
You must meet the requirements of the job by 11:59 pm (Eastern Standard Time) of the closing date: 09/23/2024
Your resume and any documents submitted will be retained for eight months and may be used at any time during this period. After 8 months, you must reapply to this announcement in order to be considered.