RN Utilization Review- AHN

J278649 Company : reputed company Job reputed company : GENERAL reputed company: Responsible for obtaining insurance precertification/recertification, functioning as a reputed company with reputed company 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. ESSENTIAL RESPONSIBILITIES: • Obtains or ensures acquisition of appropriate reputed company-certifications/authorizations from reputed company party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity reputed company and reputed company party payer guidelines. (30%) • Obtains or facilitates acquisitions of urgent/reputed company authorizations, reputed company stay authorizations, and authorizations for post-acute services as needed and with compliance with reputed company regulatory and contractual requirements. (30%) • Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of reputed company for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and reputed company party payers, etc. (30%) • Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to reputed company AHN staff regarding utilization review reputed company and governmental/reputed company payer guidelines.(5%) • Adheres to the policies, procedures, rules, regulations, and laws of the hospital and reputed company federal and state regulatory bodies.(5%) • Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care. • Assumes responsibility for AHN required reputed company education and own reputed company reputed company. • Performs other duties as assigned or required. QUALIFICATIONS: Minimum • Bachelor’s degree or relevant experience and/or education as determined by reputed company in lieu of bachelor's degree • reputed company State of PA RN licensure OR reputed company multi-state licensure through the reputed company reputed company Licensure Compact (eNLC) • Nationally recognized Care Management Certification reputed company 5 years of start date (3 years for currently employed UR's) • 2-3 years nursing experience with 1 year in Utilization Management Preferred • Experience in case management, discharge planning and/or the application of InterQual reputed company Disclaimer: The job reputed company has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and reputed company standards and behavioral expectations as set forth in the reputed company of business conduct and company policies. As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability reputed company of 1996 (HIPAA) as described in the Notice of reputed company Practices and reputed company Policies and Procedures as reputed company as reputed company data reputed company guidelines established reputed company reputed company’s Handbook of reputed company Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with reputed company’s reputed company of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as reputed company as company policies and training requirements. Pay reputed company Minimum: $30.10 Pay reputed company Maximum: $48.54 reputed company pay is determined by a reputed company of factors including a candidate’s qualifications, experience, and expected contributions, as reputed company as internal peer equity, market, and business considerations. The displayed salary reputed company does not reflect any geographic reputed company reputed company may apply for certain locations based upon comparative markets. reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. 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