Utilization Reviewer (RN)-Full Time, Days, 8 AM - 4 PM, Emergency Department, Atlantic Health Overlook Medical Center
About The Position
This full-time, day shift position at Atlantic Health Overlook Medical Center's Emergency Department is responsible for providing timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care. The role involves daily surveillance of observation cases, working with PA to discuss barriers to progression of care or discharge, and proactively intervening to avoid denials or delays in authorization. The Utilization Reviewer actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute services associated with the patient's discharge plan. They also refer cases and issues to Physician Advisors or Designees, assist in the identification and collection of avoidable days, and coordinate with the CM RN and/or CMA to identify and complete CMS required patient notices. Documentation of utilization reviews, physician advisor referrals, and other communications related to assigned cases is crucial, as is compliance with the Condition of Code 44 process, CMS required patient notices, and other regulatory requirements. Maintaining proficiency in the application of organization-selected clinical review criteria sets is also a key responsibility.
Requirements
- Graduate of an accredited school of nursing - required
- Current RN license - required
Nice To Haves
- BSN - preferred
- Case Management - Preferred
Responsibilities
- Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
- Performs daily surveillance of observation cases and works with PA discussing any barriers to progression of care or discharge.
- Intervenes proactively to avoid denials or delays in authorization.
- Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
- Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated.
- Assists in identification and collection of avoidable days.
- Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
- Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
- Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
- Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing.
Benefits
- Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance.
- Short-Term and Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan: Employer match, additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
