Registered Nurse (RN) - Utilization Review

Conifer Health Solutions

23h

About The Position

Position Summary: The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including: Utilization Management services supporting medical necessity and denial prevention; Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient; Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits.

Requirements

• Graduate of an accredited school of nursing
• 2 years of acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting
• RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy.
• Active RN license for state(s) covered.

Nice To Haves

• Academic degree in nursing (bachelor's or master's)
• Accredited Case Manager (ACM)

Responsibilities

• Responsible for providing accurate medical necessity screening and submission for Physician Advisor review.
• Securing and documenting authorization for services from payers as well as managing concurrent disputes.
• Collaborating with payers, physicians, office staff, and ancillary departments.
• Maintenance of accurate patient demographic and insurance information.
• Identification and documentation of potentially avoidable days & reporting over and underutilization
• Performs related duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed