Utilization Management Denials Specialist, RN

UM Denials Specialist, RN

On Site in Pasadena, Ca

We are currently seeking a Registered Nurse with 2 to 3 years of clinical nursing background and 2 to 3 years of Utilization Review experience. The ideal nurse for this role would also be proficient in conducting peer-to-peer meetings, mitigation of denials, have a strong understanding of the preauthorization process, the revenue cycle, reducing financial risk, be able to liaise with providers / staff, and work with payers while having regulatory awareness.

Responsibilities

• Completes denials process for requested services and IP hospital stays that fail to meet medical necessity consistent with MCG or CMS criteria.
• Completes evaluation of all external denials for medical necessity received by the hospital and coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity.
• Develops medical summaries of denied cases for review by the Medical Directors.
• Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
• Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the UM concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
• Maintains records of Outpatient and concurrent denial activity in conjunction with UM Case Management support staff. Monitors and tracks denial results, and coordinates information to report to the Medical Director and Director of Clinical Services.
• Assure quality care by adhering to standards set by the physicians
• Provide care education to patients in person or over the phone
• Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA)

Qualifications