Utilization/Denial Manager Specialist

About the Job

Location: NHRMC Business Center A

Department: Revenue Recovery

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: STD HRS - Standard-Exe or Office w flex

Exempt from Overtime: Exempt: Yes

What You'll Do

Summary:
The Utilization/Denial Management Specialist serves as the hospital expert in utilization management processes as they relate to outpatient in a bed and inpatient hospital services. Reviews all denials for medical necessity and appealability utilizing InterQual criteria. Provides clinical utilization management expertise for the CM department. Provides education, formal and informal, to facilitate denial management stragedies. Serves as liaison to key customers that include ancillary departments, physicians, and payers. Facilitates compliance with hospital Utilization Management Plan. Works under the direction of the Manager for Case Management .

Responsibilities:
1. Serves as an expert resource, and consultant related to the control of utilization of outpatient in a bed and inpatient hospital services that include certification of medical necessity based on the plan of care and utilization review.
2. Uses strong clinical knowledge base to review developmentally appropriate patient assessment, plan of care and the interventions for patient outcome. Applies InterQual guidelines criteria to evaluate denied claims for appealability.
3. Coordinates all aspects of denial management.
4. Initiates appeals on all appropriate cases of the clinical denials.
5. Assumes responsibility for maintaining, tracking and trending of all denials and appeals, including copies of all letters for the appeal process, authorization numbers, avoidable days and dollars recovered.
6. Provides denial management dashboard reports for the Manager of Case Management and Director of Clinical Resource Services as requested.
7. Liaison to medical records and patient financial services staff regarding medical record documentation for level of care, coding and correct billing status, including release of bills when suppressed for pending appeal.
8. Oversees the hospital notice of non-coverage process which includes responsibility for notification of all appropriate parties when letters are issued.
9. Participates in the orientation and education of the Case Management Team related to utilization management processes.
10. Maintains proficiency in each aspect of utilization review and management including managed care contracts.
11. Stays abreast of changes in regulatory requirements for utilization review and works with department leadership to update policies and processes as needed.
12. Performs periodic quality monitoring of utilization review processes including the development of reports and analysis of data related to utilization management processes.
13. Uses data to make suggestions for and participates in performance improvement activities as they relate to Utilization Management.
14. Maintains contact with primary external payers in order to promote effective utilization review processes and to address process improvement issues.
15. Participates in physician and physician office staff education related to acute care utilization management.
16. Demonstrates proficiency in all utilization management software and hospital information systems used to obtain clinical information on patients.
17. Demonstrates effective communication skills to collaborate with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff.
18. Maintains and promotes customer satisfaction.
19. Organizes and performs work responsibilities effectively and efficiently.

Position Requirements

Credentials:
Essential:
* Registered Nurse

Education:
Essential:
* Bachelor of Nursing

Other information:
1. Education: Graduation from accredited School of Nursing; BSN or Bachelors degree in a related field or 12 years of experience as an RN required. BSN or Bachelors degree preferred.
2. Licensure / Certifications: Current licensure as a registered Nurse in North Carolina
3. Experience: Minimum of 5 years acute care experience required. Prefer at least 3 years of recent utilization management or case management experience in an acute health care setting.
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.