Utilization ReviewQuality Associate RN
Utilization ReviewQuality Associate RN
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Salary Not Disclosed
1 Vacancy
Job Description
General Information:
Job title: Utilization Review/Quality Associate (RN)
Schedule: Fulltime 80 hours per pay period
Weekend rotation: None required
Holiday rotation: None required
Additonal Information: Remote eligible position however must hold an RN license per position requirements.
Position Summary:
The Utilization Review Nurse / Quality Associate position facilitates the prior authorization of managed care patients. The utilization review component of the position is the responsibility and performance of the utilization review function ensuring compliance with mandated regulations and having in depth knowledge of regulatory utilization review functions in a prospective payment system hospital. The quality associate role assists with assuring the continual readiness with accrediting body standards and performs a variety of complex frequently confidential and analytical tasks for the Quality Department.
Position Responsibilities:
Utilization Review:
- Obtain prior authorization and timely insurance notification.
- Communicate Provider plans to notify insurance entities.
- Evaluate and intervene if necessary appropriateness of admission and placement using MCG Guidelines in conjunction with documentation in the patients medical record.
- Coordinate with Hospitalist and care manager to facilitate timely discharge of patients.
- Coordinate as appropriate with Denial and Appeals management Case Manager Patient Accounts and other necessary parties for denials appeals and medical necessity reviews.
- Validates correct insurance information is on file. Works with registration to correct any incorrect information.
- Provides financial information and resources to uninsured/underinsured patients.
- Monitors for timely and accurate completion of regulatory forms that apply to role (MOON forms etc..
- Identify analyze and interpret data from a variety of clinical and financial sources.
- Prepare reports and information for Utilization Review meetings.
- Perform other duties as requested.
Quality Associate:
- Complete chart reviews data entry and correspond with clinic staff for Clinic Insurance Programs.
- Chart review and data entry for Hospital Quality Reporting Metrics.
- Ongoing Professional Practice Evaluation (OPPE) data collection and monitoring.
- Assist with incident reporting process and followup with leaders.
- Assist with The Joint Commission (TJC) preparation and review of clinical department processes.
- Perform other duties as requested.
Position Requirements:
- Twoyear degree in nursing required. Fouryear degree in nursing preferred.
- Must hold and maintain nursing license. RNs with an active Compact Licensure are to obtain a Wisconsin RN license within 90 days of relocation.
- BLS certification required (if working onsite)
- 1 years of Utilization Review work experience required.
- Exceptional accuracy and attention to detail required.
Knowledge Skills & Abilities
- Intermediate proficiency with computers is required including Office applications.
- Ability to work within the electronic medical record to interpret medical information as it relates to patient admissions.
- Solid understanding of insurance system including Medicare/Medicaid.
- Excellent organization and communication skills.
- Strong quantitative and analytical competency.
- Selfstarter with excellent interpersonal communication and problemsolving skills.
Required Experience:
IC
Employment Type
Full-Time
