This position assists professional nursing staff with completing concrete tasks necessary to facilitate efficient transition of patients to home, skilled nursing facilities, home care, and other transfer points following a hospitalization. This position is responsible for providing initial information to our payers, as requested. This position partners with team members to ensure optimal outcomes for discharge, length of stay and patient satisfaction. This position identifies barriers and creates opportunities for seamless transfer of complex patients.

This is a casual (0.01 FTE) role, meaning there are no guaranteeed hours/scheduled shiftsd per pay period and this position is not eligible for benefits.

Training will be six weeks, virtual, 7AM-3:30PM Monday-Friday.

Completes utilization management tasks working with payers, including compiling and faxing necessary clinical information to support timely reimbursement.

Manages work queues, quickly responding to payer needs. Provides timely feedback to utilization management nurses to promote avoidance of denials.

Obtains necessary medical reports and subsequent treatment plan requests to conduct ongoing reviews.

Documents review information in chart, as appropriate.

Works with community partners to ensure information on discharge is available to promote safe and effective transitions.

Manages all denials, including compiling of documentation, creation of appeal letters, collaboration with utilization review nurses and physician advisors.

Analyzes denials data, presents information on trends. Tracks all work related to denials/appeals.

Collaborates with health care team partners, including care transition specialists, utilization management nurses, physicians, clinicians, payers, non-clinical staff, HIMs, central business office, admissions, patient placement and clinical managers on level of care, identified barriers, reimbursement issues, and other issues related to utilization management activities.

Manages Event Management work to allow for billing within allotted timeframe

Works with Compliance to ensure documentation meets regulatory requirements.

Participates in interdisciplinary communication related to utilization review issues.

Eliminates risk for denials or underpayments, collaborating with utilization review nurses and care transition specialists, to ensure care at the correct level and by providing timely communication of clinical information to appropriate providers.

Collects data and other information required by payers to fulfill utilization and regulatory requirements.

Understands and focuses on key performance indicators.

Provides all customers with excellent service experience.

Completes all initial and annual required learning relevant to role.

Complies with all relevant laws, regulations, and policies.

Contributes to a safe work environment.

Additional Requirements:

List position requirements not described above (e.g., computer hardware/software, other office equipment, laboratory equipment, prior supervisor experience, etc.)

Ability to work independently, prioritize work, and excellent communication skills.

Excellent computer and database management skills.

Must demonstrate ability to work effectively on an interdisciplinary team.

Must be able to work flexible hours, including covering weekends and working on call, as assigned.

Must be willing to travel to other sites, as needed.

Minimum Education

Bachelors degree in social work, business, or related field; or LPN licensure and 5 years utilization review experience.

Experience:

Minimum Experience

What is the minimum level of experience needed to perform this job, if any?

One year utilization review or health care experience (may be in hospital, home care, nursing home, skilled nursing

facility, health care payer)

Preferred Experience

What level of experience is preferred for this job, but not required?

Three years health care experience

Performance improvement experience