Description

Full Time, Monday - Friday 8:00 a.m. - 4:30 p.m. This position has the potential to be remote upon completion of orientation. This individual should be able to attend in-person meetings on occasion. 

Reporting to the Chief Financial Officer, The Utilization Review Nurse is responsible for the coordination of pre-authorization for services from third party insurers.

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• A Registered Nurse or Licensed Practical Nurse licensed in the State of New Hampshire with experience in community health nursing. Experienced with Medicare Rules and Regulations and other third-party payers preferred.
• Informs the clinical management staff of any unusual request from a third-party insurance case manager.
• Responsible for coordination and monitoring of authorization requirements for coverage of services from third party insurers.
• Communicates with Clinical Manager, Vice president of Clinical Services and CFO of any problems or concerns related to clinical staff compliance with clinical update reports necessary for reauthorization process.
• Complete necessary documentation and data entry related to approvals from third party insurers in a timely, accurate manner.
• Completes the financial analysis for patients requesting subsidized care. Documents and enters information, communicate with the patient/legal representative their financial liability, if any, based on their financial analysis utilizing the agency’s current fee scaling policy and guidelines and enter information into Pathways system.
• Demonstrates knowledge of the agency’s third-party review contracts for services. Negotiates with third party payers’ appropriate charges for services in accordance with a model approved by Senior Management.
• Communicates third party insurance coverage trends to Senior Management to ensure coordination with contract management and renegotiations process.
• Attends the in services/conferences required for my position/program yearly,
• And initiates request to attend training to improve my job performance.
• Identifies problems and offers constructive suggestions/solutions.
• Participates in the orientation of new staff regarding insurance review and the role of the Utilization Management Group
• Demonstrates flexibility in the role by accepting other duties as assigned for which qualified.

Other Job Functions

• Understands and demonstrates the agency’s safety policies and procedures.
• Understands and demonstrates the agency’s safety policies and procedures.
• Adhere to the Agency’s policy and procedures regarding confidentiality and patient rights.
• Attends in services/conferences required for position/program annually.
• Utilizes supervision appropriately.

Requirements

1. A Registered Nurse or Licensed Practical Nurse licensed in the State of New Hampshire with experience in community health nursing
2. Experienced with Medicare Rules and Regulations and other third-party payers preferred