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

Date Posted: 6/7/2018

Job Snapshot

Job Description


Parallon, a leading health care company is offering a great Work from home opportunity. We are looking for dynamic candidate to be part of our team.  We offer excellent relocation and benefit packages, including 401K, bonus potential, tuition reimbursement, medical and dental plans, flexible spending plans, long-term/ short -term disability, and generous paid time off!
 
Hours range from 9:30am or 10am to 6p or 6:30pm Monday through Friday.
 
 
 
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-ASN, BSN or MSN
 
EXPERIENCE
 
2 year’s experience in either insurance or hospital UM or appeal experience  
Strong acute Utilization Review experience required
Experience with Milliman (MCG) or InterQual
 
CERTIFICATE/LICENSE RN licensure- Licensed to work California and Nevada payors
 
 
Special Qualifications:
  • Knowledge of Case Management process and the Utilization Review process
  • Knowledge of Medical Necessity Criteria
  • Knowledge of Medicare regulations as they relate to Inpatient, Observation and Outpatient services
  • Comfortable working multiple screens and familiar with working in multiple applications simultaneously (computer savvy) .
  • Familiar with IPA health plans
  • Strong critical thinking skills
  • Comfortable and experience with working in a production based environment
  • Experience working in a virtual world is a plus but not really needed
  • Ability to establish and maintain collaborative and effective working relationships
  • Ability to communicate effectively in oral, written, and electronic formats
  • Requires ability to communicate and facilitate communication with ED physicians, Admitting physicians, Consulting physicians and contracted Physician Advisors
  • Requires ability to collaborate with ED staff on all levels to facilitate a smooth process for throughput, utilization review and patient status


Job Requirements

Parallon, a leading health care company is offering a great Work from home opportunity. We are looking for dynamic candidate to be part of our team.  We offer excellent relocation and benefit packages, including 401K, bonus potential, tuition reimbursement, medical and dental plans, flexible spending plans, long-term/ short -term disability, and generous paid time off!
 
Hours range from 9:30am or 10am to 6p or 6:30pm Monday through Friday.
 
 
 
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-ASN, BSN or MSN
 
EXPERIENCE
2 year’s experience in either insurance or hospital UM or appeal experience  
Strong acute Utilization Review experience required
Experience with Milliman (MCG) or InterQual
 
CERTIFICATE/LICENSE RN licensure- Licensed to work California and Nevada payors
 
 
Special Qualifications:
  • Knowledge of Case Management process and the Utilization Review process
  • Knowledge of Medical Necessity Criteria
  • Knowledge of Medicare regulations as they relate to Inpatient, Observation and Outpatient services
  • Comfortable working multiple screens and familiar with working in multiple applications simultaneously (computer savvy) .
  • Familiar with IPA health plans
  • Strong critical thinking skills
  • Comfortable and experience with working in a production based environment
  • Experience working in a virtual world is a plus but not really needed
  • Ability to establish and maintain collaborative and effective working relationships
  • Ability to communicate effectively in oral, written, and electronic formats
  • Requires ability to communicate and facilitate communication with ED physicians, Admitting physicians, Consulting physicians and contracted Physician Advisors
  • Requires ability to collaborate with ED staff on all levels to facilitate a smooth process for throughput, utilization review and patient status