USPI Utilization Review/Appeals RN
About The Position
The USPI Utilization Review/Appeals RN 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 across United Surgical Partners International (USPI) Hospitals. 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 USPI policy Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal letters based on industry accepted criteria. Who We Are We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community. Our Story We started out as a small operation in California. In May 1969, we acquired four hospitals, some additional care facilities and real estate for the future development of hospitals. Over the years, we've grown tremendously in size, scope and capability, building a home in new markets over time, and curating those homes to provide a compassionate environment for those entrusting us with their care. We have a rich history at Tenet. There are so many stories of compassionate care; so many "firsts" in terms of medical innovation; so many examples of enhancing healthcare delivery and shaping a business that is truly centered around patients and community need. Tenet and our predecessors have enabled us to touch many different elements of healthcare and make a difference in the lives of others. Our Impact Today Today, we are leading health system and services platform that continues to evolve in lockstep with community need. Tenet's operations include three businesses - our hospitals and physicians, USPI and Conifer Health Solutions. Our impact spreads far and deep with 65 hospitals and approximately 510 outpatient centers and additional sites of care. We are differentiated by our top notch medical specialists and service lines that are tailored within each community we serve. The work Conifer is doing will help provide the foundation for better health for clients across the country, through the delivery of healthcare-focused revenue cycle management and value-based care solutions. Together as an enterprise, we work to save lives and can accept nothing less than excellence from ourselves in service of our patients and their families, every day. Careers at Tenet At Tenet Healthcare, the heart of what we do centers on caring with compassion, which ultimately creates a bond between our caregivers and patients. Everyone contributes to these moments, whether providing care directly or supporting those who do. As an organization, we provide employees with resources, tools and support to serve our patients and customers in the best way possible. We also take care of one another, helping team members further develop their career pathways and maximize their potential.
Responsibilities
- 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 USPI policy
- Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
- Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
- Preparing and documenting appeal letters based on industry accepted criteria.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
