RN Utilization Review- reputed company - Remote PA
Company :
reputed company
Job reputed company :
GENERAL reputed company
Responsible for obtaining insurance precertification/recertification, functioning as a reputed company with reputed company party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.
ESSENTIAL RESPONSIBILITIES
- Obtains or ensures acquisition of appropriate reputed company-certifications/authorizations from reputed company party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity reputed company and reputed company party payer guidelines. (30%)
- Obtains or facilitates acquisitions of urgent/emergent authorizations, reputed company stay authorizations, and authorizations for post-acute services as needed and with compliance with reputed company regulatory and contractual requirements. (30%)
- Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of reputed company for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and reputed company party payers, etc. (30%)
- Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to reputed company AHN staff regarding utilization review reputed company and governmental/reputed company payer guidelines.(5%)
- Adheres to the policies, procedures, rules, regulations, and laws of the hospital and reputed company federal and state regulatory bodies.(5%)
- Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
- Assumes responsibility for AHN required reputed company education and own reputed company reputed company.
- Performs other duties as assigned or required.
QUALIFICATIONS
Minimum
- Bachelor’s degree or relevant experience and/or education as determined by reputed company in lieu of bachelor's degree
- reputed company PA licensure as a RN
- Nationally recognized Care Management Certification reputed company 5 years of start date (3 years for currently employed UR's)
- 2-3 years nursing experience with 1 year in Utilization Management
Preferred
- Experience in case management, discharge planning and/or the application of InterQual reputed company
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As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability reputed company of 1996 (HIPAA) as described in the Notice of reputed company Practices and reputed company Policies and Procedures as reputed company as reputed company data reputed company guidelines established reputed company reputed company’s Handbook of reputed company Policies and Practices and Information reputed company Policy.
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