What are the responsibilities and job description for the RN UTILIZATION SPECIALIST - DENIALS & APPEALS position at Southwest General?
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POSITION INFORMATION
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Position summary: Utilization Specialist – Denials & Appeals will support the clinical staff, utilization specialists, denials management, and the Physician Advisors. This role will review patient medical records to ensure accurate documentation, proper level of care, and compliance with regulatory standards to prevent denials in the acute care setting.
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MINIMUM QUALIFICATIONS
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Education:
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Bachelor’s degree in nursing (BSN) preferred
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Required length and type of experience:-
Minimum of three years of clinical nursing experience, with strong preference for experience in case management, utilization review, or CDI, in the acute care setting.
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Knowledge of ICD-10 coding guidelines, Medicare/Medicaid regulations, MCG, Cerner (EMR), MS office tools, such as Word, Excel, PowerPoint.
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Ability to analyze complex medical records and identify gaps in documentation.
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Strong verbal and written communication skills to interact with physicians and insurance payers.
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Ability to collaborate with diverse teams including nurses, physicians, and administrative staff.
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Required licensure, certification or registry:-
Current RN License by the Ohio State Board of Nursing.
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Preferred certification(s): ACM/ACM-RN, CCM, CMAC, CPHQ.
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