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