UM RN Reviewer

ACHN•Chicago, IL

About The Position

Perform medical necessity reviews using InterQual and/or other medical decision support software designated by the organization and rendering determinations appropriately within established regulatory timeframes. Accurately documents required information into necessary systems according to department documentation standards and following all department workflows including correspondence to members and providers (ie. PCP notification of inpatient admissions). Documentation of discharge planning within 24 to 48 hours of admission notification. Completes admission authorization, out of network transfers, initiates concurrent authorization, completes retrospective authorization and minimizes financial risk by maintaining timely communication with all payors. Generates and process daily admission logs and appropriate denial letters as per UM process. Performs critical analysis of decisions/determinations while supporting effective team collaboration and communication. Assist with audit processes. Must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations. Coordinates with the Case Management/Care Coordination nurses to ensure members who are eligible for case management are identified and enrolled as well as to ensure contact post hospital discharge. Works closely with the health center staff, providers, hospitals, MCOS, and other outside vendors concerning scope of benefits, referrals, precertification/authorizations, and network facility participation. Participate in department committee meetings, webinars, training, projects and special assignments for cross-coverage purposes to meet strict authorization processing deadlines. Other duties as assigned.

Requirements

Associate required
Registered Nurse (RN)
current licensure in Illinois

Nice To Haves

Bachelors
Minimum 1-year nursing experience inpatient or ambulatory
Minimum 1-year Utilization Management experience
Minimum 1-year Case management experience
Experience with Epic System (EHR)
InterQual a plus
Intermediate proficiency in Microsoft Office products

Responsibilities

Perform medical necessity reviews using InterQual and/or other medical decision support software designated by the organization and rendering determinations appropriately within established regulatory timeframes.
Accurately documents required information into necessary systems according to department documentation standards and following all department workflows including correspondence to members and providers (ie. PCP notification of inpatient admissions).
Documentation of discharge planning within 24 to 48 hours of admission notification.
Completes admission authorization, out of network transfers, initiates concurrent authorization, completes retrospective authorization and minimizes financial risk by maintaining timely communication with all payors.
Generates and process daily admission logs and appropriate denial letters as per UM process.
Performs critical analysis of decisions/determinations while supporting effective team collaboration and communication.
Assist with audit processes.
Must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations.
Coordinates with the Case Management/Care Coordination nurses to ensure members who are eligible for case management are identified and enrolled as well as to ensure contact post hospital discharge.
Works closely with the health center staff, providers, hospitals, MCOS, and other outside vendors concerning scope of benefits, referrals, precertification/authorizations, and network facility participation.
Participate in department committee meetings, webinars, training, projects and special assignments for cross-coverage purposes to meet strict authorization processing deadlines.
Other duties as assigned.