JOB DUTIES AND RESPONSIBILITIES:

• Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission; performing initial, continued stay, and retrospective reviews if applicable.
• Submits initial reviews and updates using established criteria and communicates with payers as appropriate, using established processes.
• Utilize established processes with the Physician Advisors to manage second level and peer to peer reviews.
• Ensure patient status and levels of care are appropriate on admission and prior to discharge.
• Makes timely contact with payers and provides information as appropriate.
• Documents all utilization review outcomes and activities appropriately in the medical record.
• Complies with all applicable payer, state and federal regulations as well as The Joint Commission requirements regarding Care Management and Utilization Review processes.
• Acts as resource for and provides updates to the care management staff and care team for issues related to utilization review processes.
• Engages providers with concerns regarding medical necessity and appropriateness of services.
• Escalate concerns related to medical necessity and appropriateness of services to the Physician Advisors.
• Works collaboratively with the Denials Specialist and Physician Advisors to manage retrospective appeals and documents according to established policy.
• Works collaboratively with the business office/finance to ensure proper reimbursement.

PHYSICAL AND SENSORY REQUIREMENTS:

Sitting for one to two hours at a time. Standing for up to 2 hours per day, up to 10 minutes at a time. Walk on all surfaces for up to 3 hours per day, and climb stairs. Must be capable of driving a car. Fingering and handling objects frequently, uses fingers to turn pages. Frequently uses hands to write and/or type. Rarely uses hands or fingers for firm grasping or twisting/turning. Frequently uses upper extremities to lift and carry object up to 10 lbs. Rarely may be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Must have the ability to hear as it relates to normal conversations and high and low frequencies and to see as it relates to general and peripheral vision. Must have the ability to touch as related to telephone and computer keyboard.

EDUCATION:

Graduate of professional nursing program. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity. NJ RN licensure required upon hire. Advanced degree preferred. 

TRAINING AND EXPERIENCE:

At least 3 years of clinical experience as a registered nurse in an acute setting. Either 2 years of hospital or payor based utilization review experience preferred. Knowledge of Interqual and Milliman criteria preferred.

Care Management certification preferred.

Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!