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Utilization Review App Spec RN

Company: McLaren Health Care
Location: Pontiac
Posted on: May 3, 2021

Job Description:

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 leadership.
  • 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 of denials.
  • Educates health team colleagues about complex clinical appeals, utilization review, including role, responsibilities tools, and methodologies.
  • 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 activities.
  • Provides clinical productivity benchmarking and assures continuity between benchmarking and other reported patient discrepancies. Provides orientation and training to new department employees.
  • 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 societies.
  • 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.

Qualifications:

Required

  • 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 experience

Preferred:

  • Bachelor's degree in nursing
  • Three years of recent case management or utilization management experience

Keywords: McLaren Health Care, Pontiac , Utilization Review App Spec RN, Other , Pontiac, Michigan

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