1 UM Denials and Appeals RN Job in Philadelphia, PA

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UM Denials and Appeals RN

Jefferson - Center City, Philadelphia, PA

Philadelphia, PA | Full Time

$86k-107k (estimate)

2 Weeks Ago

UM Denials and Appeals RN

$86k-107k (estimate)

Full Time 2 Weeks Ago

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Jefferson - Center City, Philadelphia, PA is Hiring an UM Denials and Appeals RN Near Philadelphia, PA

004615

The UM Denials and Appeals RN facilitates, investigates and reports on the appeal processes for hospital claims denied by any payer, including Medicare for medical necessity. Examines trends in status and denials activities to promote performance improvement. Facilitates all medical necessity appeal activities.

Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

Coordinates responsibilities and activities with Utilization Management and Case Management personnel

Performs reviews on denial accounts to validate root causes by department and/or payer

Assist with preparing and coordinating follow-up activities to resolve organization deficiencies with regards to denials

Maintains knowledge of payer contracts and billing requirements

Completes work within deadlines; identifies opportunities for improvement and problem resolution

Collaborates with members of the healthcare team and providers in a positive, professional, progressive and assertive manner

Education:

Bachelors Nursing required

AND

Experience:

Minimum of 5 years’ experience in utilization management required

Excellent oral and written communication and negotiation skills. Strong organizational, time management, and problem-solving skills. Ability to work independently and exercise sound judgment and interactions with patients, families, physicians, and payers. Advanced computer skills required.

Knowledge of discharge planning, utilization management, case management, and managed care reimbursement required. Ability to be flexible, open-minded, and adaptable to change.

Registered Nurse, state of employment. Certification in InterQual criteria preferred.

Minimum Certifications, Registration or License Requirements:

Covid Vaccination is a requirement for employment at Jefferson for employees working at Jefferson’s clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson.

Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.

Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.

Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnet®-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.

Jefferson’s mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

OUR MISSION: We improve lives.
OUR VISION: Reimagining health, education and discovery to create unparalleled value
OUR VALUES: Put People First, Be Bold & Think Differently and Do the Right Thing

As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.