RN Utilization Review- reputed company - Remote PA

Company :

reputed company

Job Description :

GENERAL OVERVIEW

Responsible for obtaining insurance precertification/recertification, functioning as a liaison 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 pre-certifications/authorizations from reputed company party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria 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 action 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 practice 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 professional growth.
• Performs other duties as assigned or required.

QUALIFICATIONS

Minimum

• Bachelor’s degree or relevant experience and/or education as determined by the 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 criteria

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

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 Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy.

Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against reputed company individuals based on their race, reputed company, age, religion, sex, national reputed company, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. reputed company and its affiliates take affirmative action to reputed company and advance in employment individuals without regard to race, reputed company, age, religion, sex, national reputed company, sexual orientation/gender identity, protected veteran status or disability.

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