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Case Management Quality Review Nurse in Nashville at Parallon

Date Posted: 2/1/2019

Job Snapshot

Job Description

Case Management Quality Review Nurse

Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade Parallon remains dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.

Job Summary – The Case Management Quality Review Nurse will review post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as needed.

  • Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies
  • Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels
  • Perform accurate and timely documentation of all review activities based on policy and procedure
  • Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely.
  • Work assigned accounts in eRequest to resolve outstanding issues
  • Report insurance denial trends identified during daily operational assignments
  • Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed
  • Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.
  • Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded
  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  • Communicates effectively and professionally with physicians, hospital staff, and outside agencies
  • Participate in education and training as needed
  • Establish and maintain relationships with all customers

Job Requirements

  • Registered Nursing degree and current licensure 


  • Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred

  • RN with current state licensure