UTILIZATION REVIEW AND APPEALS RN

US:NV:Carson City Case Management

Full Time Day Shift

Summary

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.

Qualifications

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

Essential Functions

• 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 timeframes 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 InterQual )
• 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