Virtual Utilization Management Nurse (Utilization Management Experience Required) in Norcross, GA at Parallon

Job Requirements

The Utilization Management 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
 
 
 
 
 
 
Duties (included but not limited to):
 

• 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 chain of command
  
• 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.
  
• Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  
• Communicates effectively and professionally with physicians, hospital staff, and outside agencies
  
• Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc.
  
• Participate in education and training as needed
  
• Establish and maintain relationships with all customers
  
• Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  
• Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely
  
• Demonstrates commitment to teamwork and cooperation
  
• Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
  
• Other duties as assigned
  

 
 
 
 
EDUCATION
Associate’s Degree or higher preferred
 
EXPERIENCE
 
Utilization Review, appeals, denials, managed care contracting, experienced preferred
Strong computer skills
Ability to multitask
Ability to work in fast paced environment
Strong critical thinking skills
Experience with Milliman or InterQual
 
CERTIFICATE/LICENSE RN licensure