Rn Jobs in Bay Area

About The Position

Requirements

• Bachelor’s degree, or relevant experience and/or education as determined by the company in lieu of a bachelor’s degree.
• Current Pennsylvania RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC).
• Nationally recognized Care Management Certification within five years of the start date; three years for currently employed utilization review staff.
• Two to three years of nursing experience, including one year in Utilization Management.

Nice To Haves

• Experience in case management, discharge planning, and/or applying InterQual criteria.

Responsibilities

• Obtain or ensure appropriate precertifications and authorizations from third-party payers, and support placement at the appropriate level of care before hospitalization using medical necessity criteria and payer guidelines.
• Obtain or facilitate urgent and emergent authorizations, continued-stay authorizations, and authorizations for post-acute services in compliance with regulatory and contractual requirements.
• Document, monitor, intervene in, resolve, and report clinical denials, appeals, and retrospective payer audit denials.
• Collaborate with care coordination teams, performance improvement teams, physicians or physician advisors, and third-party payers to develop plans addressing denial trends.
• Maintain working knowledge of care management, utilization review, authorization, contract, and regulatory changes.
• Educate AHN staff about utilization review practices and governmental and commercial payer guidelines.
• Follow hospital policies, procedures, rules, regulations, and applicable federal and state laws.
• Communicate by telephone and electronically with outpatient providers to enhance continuity of care.
• Complete AHN-required continuing education and take responsibility for professional growth.
• Perform other duties as assigned or required.