Utilization Review Manager - Remote - Faulkner

About the role

Performs the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge.

Performs all aspects of audits and appeals, including the peer-to-peer process. Performs utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.

Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.

Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual. Demonstrates in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.

Interacts with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.

Refers cases not meeting the appropriate level of care to the Physician Advisor or EHR.

Reviews for Observation status and makes changes as needed. Accurately facilitates all documentation needed for Medicare status change from inpatient to observation (code 44).

Monitors for quality issues and documents in R.L. solutions. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.

Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.

Must be able to function independently in a busy environment. Coordinates, completes, and tracks all clinical denials and appeals. Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.

Performs and monitors for quality issues and documents in R.L. solutions. Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.

Must be able to function independently in a busy environment. Coordinates, completes, and tracks all clinical denials and appeals. Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.

Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances. Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.

Responsibilities

• Performs the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge.
• Performs all aspects of audits and appeals, including the peer-to-peer process. Performs utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.
• Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.
• Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual. Demonstrates in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
• Interacts with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
• Refers cases not meeting the appropriate level of care to the Physician Advisor or EHR.
• Reviews for Observation status and makes changes as needed. Accurately facilitates all documentation needed for Medicare status change from inpatient to observation (code 44).
• Monitors for quality issues and documents in R.L. solutions. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Must be able to function independently in a busy environment. Coordinates, completes, and tracks all clinical denials and appeals. Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Performs and monitors for quality issues and documents in R.L. solutions. Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Must be able to function independently in a busy environment. Coordinates, completes, and tracks all clinical denials and appeals. Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances. Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.

Requirements

• Bachelor's Degree in Nursing required.
• Massachusetts Registered Nurse License required.
• 5 years of Acute Care Nursing required.
• 3 year of Utilization Review and Case Management experience preferred.
• 4 or more years of Utilization Review and Case Management experience preferred.
• 6 or more years of Acute Care Nursing preferred.

Qualifications

• Staff adheres to all I C.A.R.E. Standards.
• Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan.
• Must be able to provide care for the patient despite psychosocial, educational, or physical disability.
• Basic computer skills, experience with Excel and Word, and good computation skills.
• Able to interact and communicate within a diverse community.
• Competent with InterQual Criteria.
• Competent in Utilization Review, appeals, the peer-to-peer process, and Case Management.
• Uses critical thinking skills in all interactions and recognizes the need to be solution-driven.
• Good negotiating skills with insurance companies and third-party payers.
• Proficient in the use of ECare.

Skills

• Knowledge of different industry criteria sets like Milliman and InterQual.
• In-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.
• Interacts with various third-party payers on a daily basis.
• Refers cases not meeting the appropriate level of care to the Physician Advisor or EHR.
• Reviews for Observation status and makes changes as needed.
• Accurately facilitates all documentation needed for Medicare status change from inpatient to observation (code 44).
• Monitors for quality issues and documents in R.L. solutions.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Performs and monitors for quality issues and documents in R.L. solutions.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.
• Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.
• Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.
• Maintains independence in a busy environment.
• Coordinates, completes, and tracks all clinical denials and appeals.
• Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient