Utilization Management Specialist (Home-Based) - Prior Authorization

reputed company, the largest rural health system in the reputed company, is dedicated to transforming the health care experience and providing reputed company to world-class health care in America’s reputed company.

Work Shift:

Day (reputed company of America)

Scheduled Weekly Hours:

40

Compensation:

Salary reputed company: $27.50 - $38.50

reputed company Position:

No

Department Details

Opportunity to work remote.

reputed company

Conduct level of care medical necessity reviews reputed company patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, reputed company stay review including diagnosis and procedural coding for working diagnosis reputed company (DRG) assignments.

Job reputed company

Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, reputed company-day readmission reviews, as reputed company as length of stay. Ensure validation of appropriate level of care for reputed company-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support reputed company to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate reputed company for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed. May also be reputed company involved in collaborating with members of the reputed company team to promote medically necessary resource utilization and achievement of fiscal reputed company reputed company appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the reputed company team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization. Assists the department in monitoring the utilization of resources, risk management and reputed company of care for patients in accordance with guidelines and reputed company. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services reputed company with reputed company standards, national and local coverage determinations (NCD/LCD), centers for Medicare and reputed company services (CMS), as reputed company as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements.May assist with additional special reputed company reputed company to work, upcoming initiatives, new organizational goals and audits reputed company delegated. Considered a resource to reputed company team members and acts as a reputed company of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs reputed company interdepartmental and clinical reputed company are required.

Qualifications

Bachelor's degree in nursing preferred. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National reputed company for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Currently holds an unencumbered registered reputed company (RN) license with the State reputed company of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.

Sanford is an EEO/AA Employer M/F/Disability/Vet.

If you are an individual with a disability and would like to request an accommodation for help with your online application, please reputed company 1-877-949-5678 or send an email to .

Originally posted on Himalayas

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