RN Utilization Reviewer Full Time 40 hours
RN Utilization Reviewer Full Time 40 hours
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Job Description
Job Details
Description
Registered Nurse Utilization Reviewer
At Bristol Health we begin each day caring today for your tomorrow. We have been an integral part of our community for the past 100 years. We are dedicated to providing the best possible care and service to our patients residents and families. We are committed to provide compassionate quality care at all times and to uphold our values of Communication Accountability Respect and Empathy (C.A.R.E.). We are Magnet and received the 2020 Press Ganey Leading Innovator award for our rapid adoption and implementation of healthcare solutions during the COVID-19 pandemic. Use your expertise compassion and kindness to transform the patient experience. Make a difference. Make Bristol Health your choice.
Job Summary:
The Utilization Management (UM) department reviews clinical documentation for medical necessity criteria guided treatment plans and interfaces with the insurance payers to obtain authorization for the hospital stay. An efficient UM department provides any needed information that supports the ordered level of care early on in the hospitalization. Ideal outcomes are achieved by clearly and concisely communicating the Patients severity of illness and intensity of service. Besides obtaining authorizations The UM department is heavily involved in denials management the appeal process and the Peer to Peer review process.. Successful implementation occurs when dialogue between the hospital and the insurers results in the overturning of the denied inpatient care.
Essential Job Functions and Responsibilities:
The UM Registered Nurse role is to provide direct communication with payers and to provide the clinical data needed to justify an inpatient hospital stay. The UM nurse additionally helps the team to understand the clinical guidelines and criteria sets used to support medical decision making. The appropriate Nurse Utilization Reviewer will have a strong working knowledge of nationally recognized criteria sets including Milliman MCG and Interqual. This candidate will also understand and follow CMS guidelines and implement processes as outlined in CFR 482.30 (Utilization Review) Finally the UM nurse is expected to lead a denial management process and assist with appeal letter generation.
Qualifications
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time as needed.
Employment Type
Full-Time
