This position conducts concurrent retrospective reviews for clinical, financial, resource utilization. Coordinates with Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days. Helps drive change by identifying areas of performance improvement (e.g., day to day workflow, education, process improvements, patient satisfaction). Is accountable for a designated caseload and provides intervention, coordination to decrease avoidable delays/denial of payment resources. Specific functions include: Facilitation of pre-certification and payer authorization processes, Screens pre-admission and admission process by using established criteria for all points of entry, Facilitates communication between payers, review agencies and health care team. Identifies delays in treatment or appropriate utilization and serves as a resource, application of process improvement methodologies in evaluating outcomes of care. Coordinating communication with physicians and identifies opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments Access Management and other members of the healthcare team to ensure timely communication to payers.

Estimated salary range for this position is $78166.40 - $103961.31 / year depending on experience.

Degrees:

Bachelors

Licenses & Certifications:

NACCM Care Manager Certified

ABMCM Certified Managed Care Nurse

McKesson Certified Professional in Utilization Management

AAMCN Utilization Review Professionals

RNCB Certified Rehabilitation Registered Nurse

ANCC Nursing Case Management

CDMS Certified Disability Management Specialist

NBCC Certification in Continuity of Care, Advanced

Registered Nurse

ACMA ACM Certification

CCMC Case Manager

Additional Qualifications:

RNs hired prior to 2/2012 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 5 years of hire. 3 years of hospital clinical experience preferred and 2 years of hospital or payor Utilization management review experience required. A Utilization Review or Case Management Certification is required. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards.

Minimum Required Experience:

3