Performs the activities prescribed by the Utilization Review plan seeing services of the hospital are being used appropriately. The position will collaborate with internal caregivers and various insurance providers, including Medicare, commercial and managed payers to complete concurrent reviews for approval of appropriate services. Additional responsibilities will include discharge planning, facilitating peer reviews and monitoring quality data. Other duties include reviewing medical records and preparing clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for patients. An understanding and coordination of the care continuum are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the patient. The utilization nurse will work to assess and improve the denial management, documentation, and appeals process of such findings. The utilization review nurse will assist in all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers.
Bachelor’s degree from an accredited college or university preferred. Must be a licensed RN in the State of Ohio. Must have knowledge of Utilization Review functions, Medical Record Review, and experience working with third party payer community. Must be able to effectively communicate with staff and personnel and be familiar with data collection. Must have excellent written and oral communication skills, strong computer skills and exemplary customer service skills. Previous utilization review and discharge planning experience preferred or sufficient previous experience in clinical health care and/or the managed care industry.
Full-time; day shift
Interested applicants may respond to:
Attn: Beth Brill, Dir. Human Resources
639 W. Main St., P.O. Box 309
Barnesville, OH 43713-0309
Phone: (740) 425-5103
Fax: (740) 425-5170