RN Utilization Review- AHN

Highmark Health•PA, Working at Home - Pennsylvania, PA

3d•$31 - $49

About The Position

Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.

Requirements

Bachelor’s degree or relevant experience and/or education as determined by the company in lieu of bachelor's degree
Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's)
2-3 years nursing experience with 1 year in Utilization Management

Nice To Haves

Experience in case management, discharge planning and/or the application of InterQual criteria

Responsibilities

Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines.
Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc.
Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines.
Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.
Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
Assumes responsibility for AHN required continued education and own professional growth.
Performs other duties as assigned or required.