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Utilization Management Nurse - RN

Company: Rochester Regional Health
Location: Rochester
Posted on: September 14, 2018

Job Description:

SUMMARY The Utilization Management Nurse will act as a resource on denial management as needed across the organization. Review all inpatient medical necessity denials for the health system based on InterQual and/or CMS guidelines. STATUS: Full Time LOCATION: RGH at the Medical Office Building DEPARTMENT: Utilization Management SCHEDULE: Monday through Friday, Days ATTRIBUTES BSN is preferred 3 years of acute hospital care, Case Management and/or Utilization Management experience Excellent oral and written communication and interpersonal skills Good understanding of medical management techniques and processes Strong organizational and problem solving skills Electronic Medical Record experience (Epic) Able to adapt and be flexible to changes based on health system needs RESPONSIBILITIES Documentation. Review standard UM sources for potential inpatient medical necessity denials. Review patient class in the event manager, assist with LOC determination retrospectively, and changes patient class as it relates to the Provider order for billing purposes. Meet all appeal deadlines for all payers. Demonstrates fiscal responsibility.Prepare the UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an appeal has been initiated or no appeal is necessary per UM reviews. Using nationally recognized standards of care and guidelines.Prioritizes multiple projects and tasks. Be able to work independently with minimum direction. Participation . Actively participates in Education sessions; Actively participates in analysis of utilization and quality trends and makes recommendations to management on opportunities for improvement; Participates in periodic denial meetings with Physician Advisors to review the denials that do not meet InterQual and/or CMS guidelines for his/her recommendation regarding appeal options. 91013BLS - Basic Life Support - American Heart Association (AHA); RN - Registered Nurse - New York State Education Department (NYSED) EDUCATION BS (Required) LICENSES/CERTIFICATIONS BLS - Basic Life Support - American Heart Association (AHA); RN - Registered Nurse - New York State Education Department (NYSED) Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

Keywords: Rochester Regional Health, Rochester, Utilization Management Nurse - RN, Executive, Rochester, New York

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