Utilization Review App Spec RN
Company: McLaren Health Care
Posted on: May 3, 2021
Position Summary: Coordinates/handles the appeals process for
third party payer denials, primarily RAC-related activities and
commercial appeals beyond the first level, requiring complex
clinical review. Responsible for collecting, analyzing, and
reporting clinical risk factors for level of care discrepancies.
Supports the overall quality, completeness of clinical
documentation, and intensity of service application during the
appeal process to ensure proper reimbursement is achieved.
Essential Functions and Responsibilities:
- Establishes a process of communicating and collaborating with
physicians, other team members, the client's payers, and
administrators. Works collaboratively with a diverse staff involved
in the clients' care.
- Participates in variance analysis, clinical documentation
review, assessment and presentation of cost/quality data to
appropriate internal health care providers and organizational
- Maintains a working knowledge of the appeal processes and
requirements of payers. Responsible for the communication of
clinical information required by the payer post discharge, in case
- Educates health team colleagues about complex clinical appeals,
utilization review, including role, responsibilities tools, and
- Maintains current knowledge of hospital billing processes and
participates in the resolution of retrospective billing issues
including complex clinical appeals, PACER authorization and third
party payer certification.
- Maintains accurate complete documentation of all retrospective
appeals and corresponding cases information.
- Maintains confidentiality of all information obtained while
participating in Utilization Management Access Center
- Provides clinical productivity benchmarking and assures
continuity between benchmarking and other reported patient
discrepancies. Provides orientation and training to new department
- Complies, analyzes, and evaluates quality and clinical data to
identify patterns or trends, using statistical process and controls
and various databases or software programs.
- Maintains a collaborative relationship with the medical staff
to assist with the development of clinical services and the
provision of quality patient care.
- Maintains professional and technical knowledge by attending
educational workshops; reviewing professional publications;
establishing personal networks; participating in professional
- Complies with federal, state, and local legal and certification
requirements by studying existing and new legislation; anticipating
future legislation; enforcing adherence to requirements; advising
management on needed actions.
- Performs other related duties as required and directed.
- Nursing degree from an accredited educational institution
- State of Michigan licensure as a Registered Nurse (RN)
- Three years of recent case management or utilization review
- Bachelor's degree in nursing
- Three years of recent case management or utilization management
Keywords: McLaren Health Care, Pontiac , Utilization Review App Spec RN, Other , Pontiac, Michigan
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