Reviews and responds to Corporate Compliance Audits and serves as a resource for the Health System. Reviews denial trends and identifies coding issues and knowledge gaps.
Job Responsibility
Serves as liaison between the patient and facility/physician and the third party payer.
Prepares and defends level of care and medical necessity for assigned case.
Collaborates with physician advisor, payor representative and site case managers to facilitate appropriate level of care decisions and billing status and ensures compliance with the Utilization Review standard and regulations.
Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay.
Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided.
Performs PRI’s (Patient Review Instrument), as needed.
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Job Qualification
Graduate from an accredited School of Nursing.
Bachelor’s Degree in Nursing, preferred.
Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
Preferred skills
- Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred.
- Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member’s base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).