Utilization Review And Appeals Rn

UTILIZATION REVIEW AND APPEALS RN - 5329

US:

NV:

Carson City | Nursing Support | Full Time

Posted 2 months ago

US:

NV:

Carson City Case Management

Full Time Day Shift

This position is responsible for facilitating care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources while respecting patient’s right to self-determination. This position has the overall responsibility to maintain current knowledge of disease processes, available resources, treatment options appropriate to patient population and reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage related issues.

This position collaborates with medical staff, interdisciplinary team, and external resources to screen for accurate medical necessity and appeal appropriate accounts according to internal guidelines.

Required:

• Minimum (2) years of acute care hospital patient care experience
• Current unrestricted registered nurse license in the State of Nevada
• Organizational skills, excellent verbal & written communication skills, ability to lead, coordinate diverse group in fast paced environment, critical thinking, problem solving and negotiation skills

Preferred:

• Two (2) years of experience as acute care case manager
• Bachelor of Science in Nursing
• Ability to obtain Accredited Case Manager (ACM) certification

• Transition management – Assigns appropriate length of stay, participates in readmission prevention, transition level of care and patient satisfaction
• Utilization management – Screens for accurate medical necessity using approved evidenced based criteria, application of supporting medical necessity and denial prevention utilizing physician advisor when necessary
• Reviews clinical denials and initiates process, if determined appeal appropriate according to internal guidelines
• Clinical Appeals - Responsible for drafting, finalizing, and sending clinical appeal letters in order to reverse a denial for payment on an insurance claim
• Uses provided tools and patient medical records, working within and through the regulations to develop a documented response to the denial and overturn the payer's decision
• Stays current with assigned accounts and follow-up on the appeal after submission to determine next steps to ensure appeals are overturned or upheld
• Responsible for appealing denials using clinical based rationale, the need to produce high quality work with meeting compliance time frames and production goals
• Supports billing and authorization coordination staff in reviewing high-risk and high-dollar accounts before claim submission to prevent clinical denial
• Works in partnership with Integrated Care Management Authorization Coordinators and Admin Staff
• Assists staff in care coordination and demonstrates efficient throughput while assuring care is sequenced and at appropriate level of care
• Accurately conducts a thorough, objective assessment of patient’s current status, including psychosocial, physical, financial, educational needs, treatment course and services needed
• Compliance with state and federal regulations, The Joint Commission’s standards, Center for Improvement in Healthcare Quality (CIHQ), Conditions of Participation and hospital policy
• Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient population
• Collaborates with interdisciplinary team to promote patient throughput and efficient use of resources
• Continuously demonstrates a positive attitude and understanding of case management philosophy, supports team building, and is motivated to fulfill department objectives
• Utilizes Evidence
  -based clinical guideline tool (Milliman Care Guidelines or Inter Qual)
• Documents all activity according to policy, including the electronic automated systems
• Precepts new staff members and is a resource to all staff
• Participates in department quality improvement initiatives and projects as assigned
• Ability to perform role remotely and maintain collaboration with interdisciplinary team
• Performs other related duties as assigned