Clinical Registered Nurse - Utilization Management - Remote

Cognizant Technology Solutions • Hatboro, PA

91d • $70,000 - $74,000 • Remote

About The Position

As a Registered Nurse you will make an impact by performing advanced level work related to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the Cognizant team and work collaboratively with stakeholders and other teams.

Requirements

• Educational background - Registered Nurse (RN)
• 2-3 years combined clinical and/or utilization management experience with managed health care plan
• 3 years' experience in health care revenue cycle or clinic operations
• Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews
• Intermediate Microsoft Office knowledge (Excel, Word, Outlook)
• In-patient and outpatient experience

Nice To Haves

• Epic experience
• Experience in drafting appeals disputing inpatient clinical validations audits is a plus.

Responsibilities

• Maintain ownership and responsibility for assigned accounts.
• Maintain working knowledge of applicable health insurers' internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes.
• Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment.
• Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines.
• Effectively document and log claims/appeals information on relevant tracking systems.
• Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination.
• Medical Necessity Reviews can be based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines.
• Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines.
• Identify denial patterns with clients to mitigate risk and minimize regulatory penalties.
• Escalate potential risks to client, client partners and/or leadership.
• Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination.

Benefits

• Medical/Dental/Vision/Life Insurance
• Paid holidays plus Paid Time Off
• 401(k) plan and contributions
• Long-term/Short-term Disability
• Paid Parental Leave
• Employee Stock Purchase Plan

What This Job Offers

• Job Type: Full-time
• Industry: Professional, Scientific, and Technical Services
• Education Level: Bachelor's degree