Utilization Reviewer RN

Job ID: J120721
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

GENERAL OVERVIEW:

Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.

ESSENTIAL RESPONSIBILITIES:

  • Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%)
  • Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%)
  • Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc. (30%)
  • Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines.(5%)
  • Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.(5%)
  • Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
  • Assumes responsibility for AHN required continued education and own professional growth.
  • Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

  • BA/BS and nursing diploma. Current employees grandfathered (5/14)
  • New hires must complete degree within 24 months of hire
  • Current PA licensure as a RN
  • Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's)
  • CPR Certification
  • 2-3 years nursing experience with one (1) year experience in Utilization Management

Preferred

  • Experience in case management, discharge planning and/or the application of InterQual criteria

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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