Skilled Nursing of Philadelphia -
We are seeking a motivated RN / LPN w ith experience in a healthcare environment / acute care clinical nursing. You should enjoy working with people, have excellent organizational skills as well as excellent leadership and communication skills.
Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, homecare or case management is a plus.
SKILLS :
- Thorough understanding of managed care systems and utilization review criteria
- Working knowledge of managed care and third party reimbursement
- Experience with case management, evaluation / assessment of clients
- Basic computer skills required
- Advocacy and problem solving skills
- Excellent time management and strong written and verbal communication skills
- Possess strong organizational and negotiation skills
- Possess strong team work skills
- Knowledge of community resources
- Demonstrated leadership abilities
- Experience in the use of information systems
Essential Duties and Responsibilities :
Obtains the information necessary to assess a patient's clinical condition, identify ongoing clinical care needs and ensure that the patients receive services in the setting that best meets their needs.
Determines the patient's insurance coverage and eligibility to facilitate completion of the utilization review process using payer specific criteria.
Uses MCG guidelines to establish medical necessity and determine inpatient versus observation status of the patient.
Utilizes clinical skills to provide and facilitate utilization review, continued stay reviews and utilization management of inpatient cases.
Remains current on clinical practice and protocols that affect clinical reimbursement.
Participates in meetings and committees related to this role and represents the department as necessary.
Collaborates with billing office staff to review denied claims and assists with the appeals process.
Performs other related duties as assigned.
Equal Opportunity Employer
Competitive Benefit Package Including Medical, Dental, Vision, 401K and PTO
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