Req Number 001U3R
Job Category Registered Nurse
Reviews and coordinates utilization issues concurrently and retrospectively related to potential denials from managed care and third party reviewers. Assists with planning and implementation of patient care across the continuum.
• Sorts, reviews and evaluates cases denied by all Third Party payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes.
• Maintains data tracking systems and provides reports to Patient Accounts, Director of Care Coordination, Medical Director, and Quality Management staff.
• Monitors inpatient denials and assists patients and physicians with management of the appeals process.
• Writes first and second level insurance appeal letters.
• Attends discharge planning rounds and offers recommendations and assistance to resolve complex discharge problems.
• Assists in developing new programs to enhance resource management and quality patient care.
• Assesses and monitors of quality issues, and follows-up with Quality Management.
Reviews and coordinates utilization issues concurrently and retrospectively related to potential denials from managed care and third party reviewers.
Serves as a resource to all hospital staff on managed care and third party reviewers.
Promotes staff development and education.
Participates in departmental continuous quality improvement activities and committees.
Performs related duties, as required.
• Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN Degree within five (5) years of employment date.
• Current license to practice as a Registered Professional Nurse in New York State.
• Minimum of three (3) years clinical experience including case management, utilization management, discharge planning; third party payment systems; and appeals and denial processes.