Urgent search and recruitment for a Registered Nurse (RN), Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN). Email us your resume at email@example.com.
Our client is a shared service center of the a US multinational healthcare company.
• Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.
• Additional responsibilities:
o Serves as a resource to non-clinical personnel
o Provides CDC leadership with sound solutions related to process improvement
o Assist in development of policy and procedures as business needs dictate
o Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
• Minimum of 5 years recent acute care experience with the last 2 years in a facility environment; medical-surgical/critical care experience preferred; minimum of 2 years UR/Case Management experience within the last 2 years; managed care payor experience a plus either in Utilization Review, Case Management or Appeals; Patient Accounting experience a plus
• Must possess a valid nursing license (Registered or Practical/Vocational)
• Current, valid RN/LPN/LVN licensure; Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred
(Due to the coronavirus pandemic, search and recruitment for this position is extended) Until June 2020