Utilization Review Spclst. - Case Management - Full Time - Days
6 days ago
# of Openings
Do you have clinical experience and are ready to take your career to the next level? Are you ready to participate in a fast paced Network setting? Join our Utilization Management team! Varied shifts available.
Responsibilities & Requirements
Registered professional nurse with education, knowledge and experience.
Role focuses on review of inpatient and observation admissions to ensure correct assignment of Admit status. Communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed.
Responsible for completing clinical review on all assigned patients and communicates these reviews to payers.
Identifies potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post discharge.
Review and decide the validity of medical necessity payer denials. Submits payer denial appeals.
Participates in design of work flows and procedure to reduce incidence of denials.
Current unrestricted Ohio RN licensure, BSN required.
5 years clinical experience with 2 years case management preferred
Case Management certification preferred
Familiar with MCG Care guidelines
Ability to adapt quickly to changing priorities and regulations
Experience with computers required. Experience with Microsoft applications and EPIC software preferred